Background

Alemtuzumab is an anti-CD52 monoclonal antibody therapy approved for treating RRMS. Although alemtuzumab is associated with non–MS-related secondary autoimmune events, the role pre-existing non-MS autoimmunity plays in secondary autoimmunity is unclear.

Objectives

To assess the impact of 1) pre-existing non-MS autoimmunity and 2) post-alemtuzumab thyroid autoimmunity on subsequent onset of new autoimmunity up to 9 years after initiating alemtuzumab.

Methods

In clinical trials (NCT00050778, NCT00530348, NCT00548405, NCT00930553, NCT02255656), patients were monitored for autoimmune adverse events (AEs). All patient- and investigator-reported AEs were recorded. An autoimmune event was pre-existing if it occurred prior to initiating alemtuzumab or was in the medical history database.

Results

A total of 1216 patients from the alemtuzumab clinical development program who received alemtuzumab 12 mg were included in the analysis. Ninety-six had pre-existing non-MS autoimmunity. Up to 9 years after alemtuzumab initiation, the percentage of patients with new autoimmune disease was similar in those with (35.4%) versus without (35.3%) pre-existing autoimmunity; similar percentages of patients with versus without pre-existing autoimmunity had ≥2 new autoimmune events (5.2% vs 8.2%, respectively). Most patients with thyroid disorders at baseline did not experience new autoimmunity after alemtuzumab. Treatment-emergent thyroid autoimmunity after alemtuzumab Course 1 was not associated with subsequent nonthyroid autoimmunity after Course 2 (0% of patients with vs 3.0% of patients without thyroid autoimmunity after Course 1). Similarly, thyroid autoimmunity after Course 2 did not predict nonthyroid autoimmunity after Course 3 (1.8% vs 2.0%, respectively). Among 25,292 patients treated with alemtuzumab in the postmarketing setting as of 31 March 2019, additional events (occurring 18–36 months post treatment) included autoimmune hepatitis (10.7 in 10,000) and hemophagocytic lymphohistiocytosis (2.7 in 10,000).

Conclusions

Over 9 years after alemtuzumab initiation, pre-existing non-MS autoimmunity was not associated with subsequent new autoimmune disease. Emergence of thyroid autoimmunity after Courses 1 and 2 does not appear to predict subsequent serious autoimmune disease.

STUDY SUPPORT: Sanofi and Bayer HealthCare Pharmaceuticals.

Background

Infectious agents in MS etiology have been previously investigated. Theories of pathogenic mechanisms include molecular mimicry or activation of macrophages and natural killer cells with subsequent infiltration of the blood brain barrier. Epstein-Barr virus (EBV) infection often signaled by infectious mononucleosis (IM) is a notable MS risk factors, but other infections including Chlamydia pneumoniae, among others, are also associated with MS. Adolescence is a potentially critical period for susceptibility MS and associations with exposures in adolescence such as concussion, pneumonia, BMI, and EBV/IM have been found. No studies to our knowledge have examined CNS infection as a risk factor for MS.

Objectives

To determine if CNS infection in childhood (age 0-11 years) or adolescence (age 11-20) is associated with MS risk after age 20 years.

Methods

A cohort born in Sweden between 1970-1994 followed until 31 December 2014, was identified using the Total Population Register, excluding those diagnosed with MS before age 20 years (y) (N=2,422,969). ICD codes from the National Patient Register identified diagnoses of MS after age 20y (n=4,022) (two or more diagnoses), and CNS infection (bacterial and viral) before age 20y. Diagnoses of IM, pneumonia, and other bacterial or viral infections were identified. Infections were classified as present/absent at 0-10y or 11-20y. Cox regression was used to determine associations of CNS infection with MS, with follow-up from age 20y to first MS diagnosis, adjusting for gastrointestinal, genitourinary, respiratory, skin, other infections, sex and parental socioeconomic position.

Results

CNS infection before age 11y was not associated with MS. CNS infection in adolescence was statistically significantly associated with increased MS risk producing an adjusted hazard ratio of 2.80 (95%CI 1.90-4.12). Excluding encephalomyelitis (as this includes acute disseminated encephalitis, often a precursor of MS) the estimate was 1.85 (95%CI 1.11-3.07): an accurate estimate of risk lies between these two hazard ratios. Further adjustment for other infections did not alter the estimates notably.

Conclusions

This novel finding of CNS infection in adolescence associated with MS risk suggests such infections may cause cellular damage in the CNS triggering autoimmune processes pertinent to multiple sclerosis pathogenesis. It also adds to the evidence of a critical susceptibility period in adolescence for MS initiation.

Background

We designed a web-based survey to assess the willingness and interest of European neurologists working with MS to implement precision medicine in their routine clinical practice. This study is a part of the EU-funded MULTIPLEMS grant.

Objectives

1) To assess how neurologists across European countries view the role of body-fluid biomarkers in clinical practice; 2) To survey clinical practices of diagnostic work up, therapy selection and monitoring, and frequency of data collection and clinical and paraclinical measurements.

Methods

The survey had three parts: a) demographics of respondents; b) opinion of the role of predictive, diagnostic, disease-activity biomarkers and treatment-response body-fluid biomarkers in clinical practice; c) survey of clinical practice and management of MS cases (including therapy choice and use of biomarkers) by evaluating 5 clinical cases with different characteristics (therapeutic management in drug naive patients and in patients displaying different forms of remaining disease activity, as well as stopping threapy in stable diasease since long).

Results

194 neurologists across 11 European countries responded to the survey, with a mean response rate of 45%. 57.7% were male and the mean age was 49.8 years. The importance of biomarkers in clinical practice was rated from 1 (low) to 7 (high), and it was generally high: 4.1 for predictive and disease-activity biomarkers, 5.2 for treatment-response and 5.7 for diagnostic biomarkers, with neurologists in Belgium, Denmark, Spain, Sweden and UK being the most positive. Determination of cerebrospinal fluid (CSF) oligoclonal bands was considered the most established biomarker for diagnosis (98.5% of neurologists), prediction (56.7%) and disease activity (36.5%), trailed by anti-aquaporin 4 (90.7%) and anti-myelin oligodendrocyte antibodies (85.1%) for diagnosis. Anti-JC (93.8%) and varicella virus (61.9%) and anti-drug (natalizumab (74.7%) and interferon-beta (68.6%)) were considered useful in context of therapy selection and monitoring by most neurologists, while neurofilament levels in CSF and serum and vitamin D levels were less established. Therapeutic management in the five case examples varied widely, likely as a result of differences in local and national guidelines.

Conclusions

European MS neurologists express a positive opinion on the role of body-fluid biomarkers to manage MS in clinical practice, however, these seem still to have had a limited impact on therapeutic management and selection, which also varied markedly across countries. This underscores the need for further research in this area.

Background

Intrathecal production of immunoglobulin (Ig) and the presence of cerebrospinal fluid (CSF)–specific oligoclonal bands (OCBs) are hallmarks of multiple sclerosis (MS) that persist throughout the disease course and treatment.

Objectives

To describe baseline (BL) correlations of CSF IgM and IgG production with CSF biomarkers and to assess the pharmacodynamic effects of ocrelizumab (OCR) treatment on these parameters in patients with relapsing MS (RMS) from the Ocrelizumab Biomarker Outcome Evaluation (OBOE) study (NCT02688985).

Methods

Seventy-nine of 100 total patients with RMS had available BL CSF samples for assessment of IgG OCBs, IgG and IgM (measured at University Medical Center Göttingen), with demographic, MRI and clinical parameters representative of the total RMS population. CSF samples at either 12 (n=22), 24 (n=24) or 52 (n=17) weeks postdose and from a 12-week reference arm (no OCR; n=16) were assessed for longitudinal changes.

Results

Median (interquartile range [IQR]) CSF levels at BL were as follows: IgG index, 0.79 (0.63–1.28); IgM index, 0.19 (0.11–0.33); CD3⁺ T cell number, 2.52 (0.80–5.61) cells/µL; CXCL13, 9.89 (3.91–31.50) pg/mL; CCL19, 47.95 (31.09–70.86) pg/mL; neurofilament light chain (NfL) 1280.0 (828.1–2968.9) pg/mL. At BL, IgG index and IgM index correlated moderately with levels of B cells (r=0.65, r=0.4 respectively), T cells (r=0.54, r=0.3 respectively) and CXCL13 (r=0.58, r=0.43 respectively), but not CCL19 or NfL. IgG index tended to decrease with OCR treatment and was significantly reduced by 52 weeks (n=17/79; median [IQR] change from BL −9.5% [−20.4% to −0.1%]; p<0.02) compared with stable levels in the reference arm. While IgG OCBs were detected at BL in all patients, IgG OCBs tended to decrease with OCR treatment, with three of 17 patients having no detectable IgG OCBs at 52 weeks. Reductions in IgM index were not observed with OCR treatment.

Conclusions

Baseline CSF levels of B cells, T cells and CXCL13 correlated with IgG index and to a lesser degree IgM index in patients with RMS from the OBOE study. Significant reductions were observed in IgG index with OCR treatment, along with a trend toward reduced OCBs, with three patients showing no detectable OCBs. These data suggest that OCR impacts CSF Ig production, a hallmark of MS not previously thought to be affected by B-cell depletion therapy. These 1-year observations need to be confirmed with longer-term data and correlated with clinical response.

Background

Small non-coding RNAs (sncRNAs) are important regulators of gene expression at the transcriptional and post-transcriptional levels in various biological contexts, such as regulation of immune system functions, homeostasis, and autoimmunity development. While the role of microRNAs (miRNAs) in multiple sclerosis (MS) has attained major interest, studies investigating other sncRNA classes, especially in the target central nervous system compartment, are still scarce.

Objectives

We aimed to perform a comprehensive, comparative analysis of all classes of sncRNAs in matching peripheral blood mononuclear cells (PBMCs), plasma, cerebrospinal fluid (CSF) cells, and cell-free CSF from MS patients and controls.

Methods

23 relapsing-remitting (RRMS, n=12 in relapse, n=11 in remission), 6 secondary progressive (SPMS) MS patients and 16 non-inflammatory and inflammatory neurological disease controls (NINDC, n=11; INDC, n=5) were included in the analysis. We utilized Small-seq (Faridani et al., Nat Biotechnol. 2016) to quantify sncRNA transcripts.

Results

We observed distinct and variable profiles of sncRNA classes across all analyzed cellular and biofluid compartments. While miRNAs were the most abundant class of sncRNAs in PBMCs and plasma, transfer RNAs represented the most abundant class in CSF cells and cell-free CSF. Furthermore, we observed an opposing quantitative pattern of small nuclear, nucleolar, transfer RNAs, and miRNAs changes between the blood and CNS compartments. In CSF cells, 133/133 and 115/117 differentially expressed sncRNAs were increased in RRMS relapse compared to remission and RRMS compared to NINDC, respectively. In contrast, 65/67 differentially expressed PBMC sncRNAs were decreased in RRMS compared to NINDC. These findings underscore the importance of including both the peripheral and intrathecal compartments in studies investigating the role of sncRNAs in MS.

Conclusions

Our findings demonstrate widespread alterations of several classes of sncRNAs, particularly during the relapse phase in CSF cells. Genome-wide small non-coding RNA profiling provides therefore an informative moleculer panel for addressing MS pathogenesis, where further research may lead to the identification of novel biomarkers and possible treatment targets.

Background

Fingolimod (FGL) is an oral disease-modifying therapy (DMT) for patients with relapsing-remitting multiple sclerosis, introduced in Sweden 2011. Already from launch, FGL was included in the Swedish “Immunomodulation and Multiple Sclerosis Epidemiology Study” (IMSE) in order to enable long-term surveillance of effectiveness and safety aspects in a large population-based cohort.

Objectives

To assess the relation between Expanded Disability Status Scale (EDSS) and patient-reported outcome measurements (PROMS) in patients treated with FGL.

Methods

Swedish MS patients are registered into the nationwide Swedish MS Registry. Demographic data, EDSS and the Multiple Sclerosis Impact Scale (MSIS-29), Symbol Digit Modalities Test (SDMT), European Quality of Life - 5 Dimensions Test (EQ-5D), Visual Analog Scale (VAS) were collected for FGL patients who agreed to participate in the IMSE 2 study. Spearman rank correlation were used to determine associations between EDSS and PROMS.

Results

From September 2011 until June 2020, 1670 MS patients (68% female) were included in IMSE 2. Mean age at treatment start was 39 years and mean treatment duration in the entire cohort was 44 months (M). Out of 1670 patients, 560 (63% female) had been treated with FGL for at least 60 M. Mean age was 40 years and mean treatment duration 81 M. Significant (p<0.05) correlations was found between EDSS and all PROMs. The strongest correlation was found between the physical component of MSIS-29 for both baseline (r=0.60, n=778) and 60 M (r=0.64, n=109). Also, for both EQ-5D and VAS, Spearman coefficient indicates a moderate correlation for baseline (EQ-5D; r=-0.48, n=744 and VAS; -0.43, n=706) and 60 M (EQ-5D; r=-0.47, n=102 and VAS; -0.48, n=102) respectively. The correlation between EDSS and SDMT and the psychological component of MSIS-29, both indicated a weak correlation for baseline (SDMT; r=-0.28, n=771 and MSIS-29 psychological; r=0.28, n=778). For 60 M the correlations were stronger and indicated a moderate correlation (SDMT; r= -0.42, n=114 and MSIS-29 psychological; r=0.33, n=109).

Conclusions

The observed correlations between EDSS and PROMs in patients treated with FGL indicate a weak correlation with SDMT and the psychological component of MSIS-29. These results highlight that different scales capture different dimensions of the physical and psychological impact of MS from the patient’s perspective and have important functions which should continue to be followed.

Background

Elevated levels of plasma neurofilament light chain (pNfL) is associated with increased disease activity, physical disability and reduced treatment response in persons with multiple sclerosis (MS). However, the association between environmental exposures such as cigarette smoking and pNfL levels is not clear.

Objectives

To investigate the association between cigarette smoking, as one of the most prominent environmental factor associated with MS disease activity, and pNfL-levels in MS.

Methods

This is a retrospective population-based cohort study. Blood samples from incident MS cases were collected at time of diagnosis (from 2001). Concentrations of pNfL were determined using antibodies from UmanDiagnostics and the high-sensitive Single Molecule Array (SimoaTM) NF-light® Advantage kit. We assessed the impact of self-reported cigarette smoking habits at time of sampling on age-stratified pNfL levels above 80^th, 95^th, and 99^th of non-MS controls' percentiles (>C80, >C95, and >C99).

Results

pNfL levels were measured in 2881 MS cases with smoking history of which 320 (11.1%) were current regular smokers and 828 (28.7%) were past regular smokers (median years since quitting 6; IQR 1 to 14). Current smoking was associated with significantly increased odds ratios (OR) of having pNfL-levels >C80, >C95 and >C99 with OR ranging from 1.27 (95% CI: 0.96-1.68) to 1.70 (95% CI: 1.24-2.33) comparing current smokers to never smokers and 1.44 (95% CI: 1.06-1.94) to 1.6 (95% CI: 1.12-2.27) comparing current smokers to past smokers. The OR of having pNfL-levels >C80, >C95 and >C99 in past smokers who quitted 6 to 10 years ago, compared to current smokers, ranged from 0.6 (95% CI: 0.39-0.92) to 0.55 (95% CI: 0.30-0.95), and from 0.62 (95% CI: 0.43-0.89) to 0.53 (95% CI: 0.31-0.87) in those with >10 years since quitting smoking. Although decreased, the ORs were not significant among those quitting smoking 1 to 5 years before sampling (P>0.05).

Conclusions

Current regular smoking is associated with significantly increased risk of displaying high pNfL levels in MS patients, which argue for a negative effect on disease activity. In contrast, there was a beneficial effect of quitting smoking that increased with time since stopping. Our findings support the rational for life style counselling in MS.

Background

Increasing evidence suggest that early initiation of highly effective disease modulatory therapies (DMTs) reduce disability progression in relapsing-remitting MS (RRMS), but few studies strive to identify the most successful DMT strategy for new onset RRMS by also including drug survival. The CombatMS study is a Swedish nationwide observational drug trial involving all Sweden´s University Clinics (NCT03193866).

Objectives

To compare effectiveness of different DMT strategies for early RRMS, defined as treatment start latest two years after symptom onset.

Methods

The CombatMS population comprises 3500 RRMS patients starting a first DMT or doing a first DMT switch between Jan 1st 2011 to Oct 31st 2018, who from study start (June 2017) undergo an annual structured follow up with EDSS, patient reported outcomes and imaging. For this study we selected patients aged 18 to 50 years starting a first DMT within two years from symptom onset with a previously registered EDSS score ≤ 12 months before or ≤ 2 months after treatment start. We restricted the analysis to the four most frequent DMT choices in this category: interferons (INF), natalizumab (NTZ), dimethyl fumarate (DMF) and rituximab (RTX), resulting in total study population of 954 patients. We used an ever-treated approach, disregarding if the patient later switched or stopped therapy. Two-year disability progression was determined by comparing the baseline EDSS score to the EDSS score closest to two years, while relapse rate and drug survival were measured for a two-year follow-up period from treatment start.

Results

The proportion of patients experiencing disability progression was 7.3 % (NTZ), 7.6 % (RTX), 12.4 % (DMF) and 19.2 % (INF). After adjusting for baseline differences in age, sex, region of residence, baseline EDSS, relapse rate before DMT start, and follow-up time, only the difference between RTX and INF remained significant. Two-year drug survival ranged from 38.3 % (INF) to 92.4 % (RTX), with these two extremes being significantly different from all other DMTs. Annualized relapse rates varied from 0.04 (RTX) to 0.27 (INF), with significant difference between all other DMTs and INF and between RTX and DMF.

Conclusions

We observe relatively large differences in two-year outcomes across the studied DMTs, where the most striking findings are that patients initiating INF perform worse and those starting RTX better in most comparisons. Longer observation times will be needed to inform on risk-benefit with different DMT choices beyond two years.

Background

Background: The envelope protein of the human endogenous retrovirus type W (HERV-W ENV) is expressed in chronic active MS lesions. Preclinical models have shown that HERV-W ENV activates microglia, prevents maturation of oligodendrocyte precursor cells, and leads to neuronal death. Following the effects of a B-cell depleting, anti-inflammatory therapy, rituximab (RTX), with temelimab (TML), a humanized, IgG4-κ monoclonal antibody against HERV-W ENV represents a novel therapeutic approach against neurodegenerative features of MS.

Objectives

Objective: To present safety preclinical results on the interaction of RTX and TML, and the trial design of the ProTEct-MS study.

Methods

Design/Methods: Interactions between RTX and TML were studied in vitro in high density-peripheral blood mononuclear cells (PBMCs) and ex-vivo in a whole blood loop system from fresh human blood.

ProTEct-MS is a randomized, double-blind, placebo controlled, parallel group study. Enrolment commenced in 2020/6 and will be completed in 2020/12. Patients with RMS (2017 McDonald criteria) (N=40) being previously treated for ³12 months with RTX are randomized (1:1:1:1) to monthly iv TML (18, 36 or 54mg/kg) and placebo for 48 weeks.

Eligibility criteria: age 18-55 yrs, Expanded Disability Status Scale (EDSS) of 2.5-5.5 at screening; clinical worsening in ³1 neurological domain as assessed by EDSS, 6MWT or T25FW, or cognitive functioning as assessed by SDMT over the last year.

Primary objective: assessment of safety and tolerability of TML

Secondary outcome measures: MRI: change of brain atrophy, lesion volume and magnetization transfer ratio

Results

Results: Co-administration of TML with RTX was overall comparable to vehicle for all blood parameters assessed including cytokine levels of all five donors tested in both in vitro and ex-vivo assays. Co-administration of TML with RTX did not affect the functionality profile of either compound. By September 2020, 25% of patients are expected to be randomized, providing baseline clinical and MRI characteristics.

Conclusions

Conclusions: Preclinical safety experiments of the drug combination showed no evidence against the use of TML following RTX in humans. ProTEct-MS study patients represent a RMS cohort with progression in absence of relapse activity (PIRA,) i.e. whose present clinical condition is stable under RTX therapy, enabling TML's effects on attenuating mechanisms of progression to be measured without interference by acute inflammatory activity.

Background

Alemtuzumab (ALZ) is an approved disease-modifying therapy (DMT) for relapsing-remitting multiple sclerosis (RRMS). Post-marketing surveillance is important to assess the long-term safety and effectiveness in a real-world setting. ALZ has therefore been included into the Swedish post-market surveillance study “Immunomodulation and Multiple Sclerosis Epidemiology Study” (IMSE) upon launch in Sweden (March 2014).

Objectives

To track effectiveness and long-term safety of ALZ in a real-world setting, with focus on patients treated with ALZ for at least 36 months.

Methods

Swedish MS patients are registered into the nationwide Swedish MS Registry (NeuroReg). IMSE 3 includes all patients starting ALZ treatment with annual clinical measures obtained from NeuroReg; Extended Disability Status Scale (EDSS), Multiple Sclerosis Severity Scale (MSSS), Symbol Digit Modalities Test (SDMT), Multiple Sclerosis Impact Scale (MSIS-29), European Quality of Life – 5 Dimension Test (EQ-5D) and Visual Analogue Scale (VAS).

Results

A total of 118 patients (59% female; 95% RRMS) were included in IMSE 3 between March 2014 and June 2020. Out of 118 patients, 93 had been treated for at least 36 months (62% female), of which 10 patients had switched to another DMT. Mean age at treatment start for patients treated ≥ 36 months was 34 years and mean treatment duration was 54 months. Mean number of drugs prior ALZ initiation was 2.4. Most of the patients (40%, n=37) switched to ALZ from natalizumab or were treatment naïve (13%, n=12) prior ALZ. The mean number of relapses was reduced from 0.72 one year before ALZ initiation to 0.10 during the first treatment year, followed by 0.08 the second treatment year and 0.06 the third year of ALZ treatment (n=79, 15% missing data). In patients treated ≥ 36 months significant improvements in mean baseline compared to 36 months were seen for MSSS (3.3 ± 2.7 to 2.3 ± 2.3, n=44) and EQ-5D (0.7 ± 0.3 to 0.8 ± 0.3, n=50), while SDMT showed significantly worsened results after 36 months (64.8 ± 17.5 to 56.2 ± 12.7, n=59). EDSS, MSIS-29 and VAS scores remained stable. A total of 36 adverse events were reported to the Swedish Medical Products Agency, 13 events were classified as serious and 23 events as non-serious. Two patients died during ALZ treatment, one of which was associated to ALZ treatment, and died in association with the first ALZ treatment cycle due to fulminant viral hepatitis.

Conclusions

Patients treated with ALZ for at least 36 months improved or remained stable across all effectiveness measures except SDMT. Continued follow-up is needed to address long term effectiveness and safety of ALZ.

Background

Background: Teriflunomid (TFM) is an oral therapy for relapsing-remitting multiple sclerosis (RRMS), which has been included in the Swedish post-market surveillance study “Immunomodulation and Multiple Sclerosis Epidemiology” (IMSE).

Objectives

Objectives: To assess the long-term safety and effectiveness of TFM for patients treated in a real-world setting over time.

Methods

Methods: A large majority of MS patients are registered into the nationwide Swedish Neuro Registry (NeuroReg). The IMSE 4 study obtains descriptive data of adverse events (AEs), Extended Disability Status Scale (EDSS), Multiple Sclerosis Severity Scale (MSSS), Symbol Digit Modalities Test (SDMT), Multiple Sclerosis Impact Scale (MSIS-29), European Quality of Life - Five Dimensions Test (EQ-5D) and Visual Analog Scale (VAS) from NeuroReg. Effectiveness measures were assessed using the Wilcoxon Signed Rank Test and drug survival using the Kaplan-Meier curve.

Results

Results: 609 TFM-treated patients had been included in the IMSE 4 study from March 2014 to June 2020, 70% were female and mean age at treatment start was 46 years. Mean treatment duration was 27 months and 89% of the patients had RRMS. The most common prior treatment was interferon beta or glatiramer acetate (39%) and 17% of the patients were treatment naïve. The overall one- two- and three- year drug survival rates were 73%, 59% and 48% respectively. 307 (50%) patients had discontinued treatment at some point, of which 34% started rituximab treatment (36% had no new treatment registered). The most common reasons for discontinuation were AEs (42%) and lack of effect (40%).

204 patients had been continuously treated with TFM for ≥36 months and significant changes in mean baseline values compared to values at 36 months were noted only for EDSS (2.0 ± 1.6 to 2.3 ± 1.8, n=49). All other clinical measures were stable.

A total of 68 AEs were reported of which 20 events were classified as serious (S). The most common AE category was skin and subcutaneous tissue disorders for both serious and non-serious (NS) AEs (S: 25%, NS: 21%).

Conclusions

Conclusions: NeuroReg proves to function well as a post-marketing drug surveillance platform, providing data regarding drug effectiveness and AEs. Patients starting TMF are older at treatment start than patients initiating most other DMTs, which may explain the lack of significant improvement in most clinical measures and the negative outcome of the EDSS scores. A longer follow-up period is needed to assess the real-world effectiveness and safety of TMF.

Background

Background: Cladribine is a deoxyadenosine analogue prodrug. Cladribine tablets (CT) are administered in two courses, 12 months apart, for patients with relapsing multiple sclerosis (RMS). CT are included in the Swedish post-market surveillance study “Immunomodulation and Multiple Sclerosis Epidemiology” (IMSE).

Objectives

Objective: To assess the safety and effectiveness of CT in a real-world setting with focus on patients treated at least 12 months.

Methods

Methods: Descriptive data of Extended Disability Status Scale (EDSS), Multiple Sclerosis Severity Scale (MSSS), Symbol Digit Modalities Test (SDMT), Multiple Sclerosis Impact Scale (MSIS-29), European Quality of Life - 5 Dimensions Test (EQ-5D), Visual Analog Scale (VAS), relapses and Adverse Events (AEs) is obtained from the nationwide Swedish Neuro Registry (NeuroReg). Effectiveness measures were assessed using the Wilcoxon Signed Rank Test and relapse rates were tested using the paired samples T-test.

Results

Results: 85 patients were included in the IMSE 10 study since CT were introduced on the Swedish market in April 2018. 42 patients were treated for at least 12 months. Five AEs were reported since the study start, four were classified as infections and infestations.

25 % of the entire cohort was treated with CT as their first MS drug. 13 % were treated with natalizumab and 12 % with dimethyl fumarate prior to CT. Five AEs were reported since the study start, four were classified as infections and infestations.

Relapse data was available for 27/42 patients in the 12-month cohort. The number of reported relapses decreased significantly from 208.6 per 1,000 patient years before treatment start to 83.6 during treatment. Only three patients in this cohort experienced a relapse during treatment of which two were during the first treatment year.

Significant improvements in mean values at 12 months of treatment compared to baseline were noted for MSSS for the 12-month cohort (n=17). All other tests remained stable but significantly unchanged after one year of treatment.

Lymphocyte levels decreased from a mean of 2.4 x 10⁹/L at treatment start (n=8) to 1.2 x 10⁹/L after 12 months of treatment (n=6) in the 12-month cohort. No patients were below the 0.8 x 10⁹/L limit at 12 months.

Conclusions

Conclusions: CT treatment demonstrates clinical stability in patients treated 12 months. However, continued follow-up is needed to assess the effectiveness and safety of CT over a longer time to assess if these results sustain after the final treatment course has been administered.

Background

Background: Dimethyl fumarate (DMF) is an oral therapy for relapsing-remitting multiple sclerosis (RRMS). DMF is included in the Swedish post-market surveillance study “Immunomodulation and Multiple Sclerosis Epidemiology” (IMSE).

Objectives

Objectives: To assess the effectiveness and safety of DMF with focus on patients treated at least 36 months in the IMSE study.

Methods

Methods: Descriptive data of Extended Disability Status Scale (EDSS), Multiple Sclerosis Severity Scale (MSSS), Symbol Digit Modalities Test (SDMT), Multiple Sclerosis Impact Scale (MSIS-29), European Quality of Life - 5 Dimensions Test (EQ-5D), Visual Analog Scale (VAS) and Adverse Events (AEs) is obtained from the nationwide Swedish Neuro Registry (NeuroReg). Effectiveness measures were assessed using the Wilcoxon Signed Rank Test and drug survival using the Kaplan-Meier curve.

Results

Results: 2349 DMF-treated patients were included between March 2014 and June 2020 with an overall drug survival rate of 45%. The main reasons for discontinuation were AEs (50%) and lack of effect (30%). 186 AEs were reported to the Swedish Medical Products Agency, of which 59 were serious. A total of 8 patients have died during DMF treatment or within 6 months of treatment discontinuation.

36 month cohort: 940 patients had continuous treatment for at least 36 months. This cohort had a mean age of 42 years and a mean treatment duration of 56 months. The majority (50%) had switched from interferon or glatiramer acetate, and (24%) were treatment naïve (TN).

Significant improvements in mean values at 36 months of treatment compared to baseline for the 36-month cohort were noted for MSSS, SDMT, MSIS-29 Psychological, EQ-5D and VAS. When TN patients were solely assessed (n=230) improvements were noted for all above mentioned measures as well as MSIS-29 Psychological. The remaining patients in the cohort; treatment experienced patients (n=710) displayed significant improvements only for MSSS, MSIS-29 Psychological and EQ-5D. TN patients had a mean duration from diagnosis to treatment start of 5 months compared to 91 months for the remaining cohort. TN were also younger than the remaining cohort (37 years vs 43 years).

Conclusions

Conclusions: DMF demonstrates clinical improvements in patients treated 36 months, more pronounced in TN patients. However; due to the high discontinuation rate there is an unavoidable selection bias. Continued follow up is needed to assess the effectiveness and safety of DMF over longer time periods in a real world setting.

Background

Natalizumab (NTZ) is a highly effective disease modulatory treatment for relapsing-remitting multiple sclerosis (RRMS). Post-marketing surveillance is important for evaluation of long-term safety and effectiveness in a real-world setting. To this end, the “Immunomodulation and Multiple Sclerosis Epidemiology Study” (IMSE 1) was initiated upon NTZ launch in Sweden (August 2006).

Objectives

To follow-up the long-term effectiveness and safety of NTZ in a real-world setting, with focus on patients treated at least 10 years.

Methods

IMSE 1 includes patients starting NTZ treatment and data is collected from the nationwide Swedish Neuro Registry (NeuroReg). Adverse events (AEs), JC-virus status (JCV) and clinical effectiveness measures are registered in NeuroReg prospectively. Effectiveness measures were assessed using the Wilcoxon Signed Rank Test.

Results

A total of 3291 patients were included in the IMSE 1 study from August 2006 until June 2020 (72% female; mean age 36 years; 80% RRMS; mean treatment duration 50 months). 171/3291 patients (5%) had been treated for at least 120 months (73% female; men age 36 years; 87% RRMS; mean treatment duration 139 months). A total of 64% (110/171) were treated with interferons or glatiramer acetate prior to NTZ treatment. Over the duration of follow-up discontinued 21% (35/171) their NTZ treatment of which 46% (16/35) discontinued due to JCV positive (JCV+). In total, 27% (46/171) of these patients were JCV+ with a mean JCV index of 1.2±1.0 (4% missing data). The mean number of relapses were reduced from 0.84 one year before NTZ treatment start to 0.00 during the first treatment year (12% missing data). All clinical effectiveness measures (Extended Disability Status Scale (EDSS), Multiple Sclerosis Severity Scale (MSSS), Multiple Sclerosis Impact Scale (MSIS-29) and Symbol Digit Modalities Test (SDMT)) showed improvement in mean between baseline and 120 months. However, only MSSS, MSIS-29 psychological and SDMT were statistically significant. Over the entire observation time, 114 Serious AEs had been reported to the Swedish Medical Product Agency and included nine cases (2 fatal) of progressive multifocal leukoencephalopathy (PML) of which eight between year 2008 and 2012, and one in 2018. 17 patients died during or within 6 months of last NTZ infusion. None were judged to be directly associated with NTZ.

Conclusions

NTZ is generally well tolerated with sustained effectiveness regarding cognitive, physical and psychological measures, as well as relapse-control.

Background

Natalizumab (NTZ) is approved for treatment of relapsing-remitting multiple sclerosis. Progressive multifocal leukoencephalopathy (PML) caused by the reactivation of the John Cunningham virus (JCV) is a safety concern with NTZ treatment.

Objectives

To describe the long-term drug persistence in natalizumab JCV negative patients in a Swedish population-based setting.

Methods

The IMSE-1 study obtains demographic, clinical and safety data from the Swedish population-based Neuro Registry. Key inclusion criteria for this study were NTZ patients with a negative JCV values. Drug persistence was defined as the duration of time from initiation to discontinuation of therapy, estimated by the Kaplan-Meier approach, and Cox regression was used to identify possible independent factors related to drug discontinuation.

Results

A total of 1177 NTZ patients were included,76% were female and the mean age at treatment start was 34.3 (SD 10.0) years. The mean treatment duration was 5.5 (SD 3.0) years. 57% of the patients switched to NTZ from interferons and Copaxone, 27% were treatment naïve, and 14% from other disease-modifying treatments. At 10 years following treatment initiation of NTZ 6.5% had discontinued due to lack of efficacy, 6.7%, 24.4% and 28.9% due to adverse events, pregnancy and other reasons, respectively. An increased EDSS score at baseline increased the risk of discontinuation due to the lack of effect (HR 1.30; 95% CI 1.04-1.62), but the opposite was true for SMDT at baseline (HR 0.97; 95% CI 0.95-0.99). Also, relapses during treatment initiation had a significant effect on the risk of discontinuation due to lack of efficacy (HR 1.67; 95% CI 1.31-2.11). Only calendar year of symptoms and calendar year of treatment initiation had a significant effect on drug discontinuation due to adverse events (HR 1.11; 95% CI 1.04-1.18, HR 1.25; 95% CI 1.10-1.41).

Conclusions

Data from the Swedish IMSE-1 study suggest that long-term drug discontinuation due to a lack of efficacy or adverse events are minimal, and that the most common reason for treatment discontinuation was due to pregnancy.

Funding: The IMSE-1 study is funded in a scientific collaboration agreement with Biogen.

Background

Dimethyl fumarate (DMF) is an oral therapy approved for patients with relapsing-remitting multiple sclerosis (RRMS), and in which lymphocyte decline is a known pharmacodynamic effect of DMF. Currently, research has suggested meaningful lymphocyte reconstitution may occur within 2-4 months after discontinuation of DMF. To date, the only factor shown to be associated with a slower rate of recovery is the duration of lymphopenia.

Objectives

To describe lymphocyte count profiles following discontinuation of Dimethyl fumarate (DMF) due to lymphopenia in a nationwide Swedish population-based setting.

Methods

The IMSE-5 study obtains demographics, clinical and safety data, including absolute lymphocyte count (ALC), from the Swedish population-based Neuro Registry. Key inclusion criteria were RRMS patients, treatment with DMF for at least 3 months, age >18 years at initiation, had ALC values at start of DMF treatment, during treatment, and following discontinuation of DMF treatment. All patients had discontinued DMF due to lymphopenia. The least square mean estimation of ALC values at different time points was calculated using Linear Mixed Models

Results

A total of 18 DMF patients were included, 72% were female and the mean age at treatment start was 51.3 years. The mean treatment duration was 3.1 (SD 0.8) years, and 22% were treatment naïve, 50% had switched from interferons or glatiramer acetate (GA). and three patients switched from natalizumab and fingolimod. The estimated ALC values following discontinuation of DMF due to lymphopenia compared to the time for discontinuation significantly increased during follow up (p<0.001). E.g. at date of drug discontinuation mean ALC was 0.35x10⁹/L (95% CI 0.33-0.37), in 6 weeks following discontinuation ALC was 0.50 x10⁹/L (95% CI 0.26-0.74) and in 12 weeks ALC increased to 0.91 x10⁹/L (95% CI 0.74-1.07). The mean time from discontinuation to a new treatment initiation following DMF was 99.8 (SD 88.5) days; and 50% switched to rituximab and two patients to teriflunomide, and one to GA.

Conclusions

Data from the Swedish IMSE-5 study suggest that a lymphocyte reconstitution occurs within 12 weeks following the discontinuation of DMF. However, larger datasets will be needed to verify this finding

Funding: The IMSE-5 study is funded in a scientific collaboration agreement with Biogen.

Background

Subcutaneous peginterferon beta-1a (PegIFN) was approved for relapsing-remitting multiple sclerosis (RRMS) in Europe 2014. The clinical trial program showed that PegIFN reduced the relapse rate and proportion with disability progression compared to placebo. At its launch in Sweden, PegIFN was included in the Swedish “Immunomodulation and Multiple Sclerosis Epidemiology Study” (IMSE 6), providing possibilities to track long-term effectiveness and safety in a population-based setting.

Objectives

To follow-up the long-term effectiveness and safety of PegIFN treatment in Swedish patients in a real-world context.

Methods

Data was obtained from the nationwide Swedish Neuro Registry (NeuroReg) between June 2015 and May 2020. Effectiveness measures were assessed using the Wilcoxon Signed Rank Test and drug survival using the Kaplan-Meier curve.

Results

A total of 364 patients (78% female; 87% RRMS; mean age at treatments start 43 years) were followed up to 57 months (mean 20 months), of which 200 (55%) patients had been treated for at least 12 months. The majority of the patients had switched from other injectables (164 patients, 45%) or were treatment naïve (90 patients, 25%) prior to treatment with PegIFN. Over the duration of the follow-up, 68% (247/364) patients discontinued their PegIFN treatment for various reasons (60% adverse events, 24% lack of effect) and switched mainly to rituximab (105 patients, 43%). The overall drug survival was 32%, 40% for men and 30% for women. The one- and two-year drug survival rate was 57% and 40%, respectively. The mean number of relapses were reduced from 0.35 one year before treatment start to 0.11 one year after (35% missing data). All clinical effectiveness measures (Extended Disability Status Scale (EDSS), Multiple Sclerosis Severity Scale (MSSS), Multiple Sclerosis Impact Scale (MSIS-29), European Quality of Life – 5-Dimension test (EQ-5D), Visual Analogue Score (VAS) and Symbol Digit Modalities Test (SDMT)) remained stable. Statistically significant changes were observed in SDMT (p=0.027). A total number of 18 adverse events (6 serious) were reported to Swedish Medical Product Agency.

Conclusions

These findings are consistent with PegIFN being a safe disease modifying treatment, however, a relatively high proportion of patients switched due to adverse events. All clinical effectiveness measures remained stable in patients treated with PegIFN for at least 12 months in this nationwide population-based real-world study. Longer follow up is needed to address the long-term effectiveness.

Background

Induction therapy that cause long-term cessation of disease-specific inflammation is an emerging treatment option for multiple sclerosis (MS). Alemtuzumab was the first induction-type therapy to be approved for relapsing-remitting MS (RRMS) in 2013/2014, while autologous hematopoietic stem cell transplantation (AHSCT) is an induction-type medical procedure which has been used to treat MS since 1995 and was approved for use in RRMS in Sweden in 2016.

Objectives

This study aimed to assess safety outcomes for alemtuzumab and AHSCT, compared to non-induction disease-modifying therapies.

Methods

We performed a population-based cohort study linking the Swedish MS Register to national healthcare registers. Alemtuzumab, AHSCT, and a matched reference group of non-induction therapies (natalizumab, dimethyl fumarate, rituximab, fingolimod) were included if started between 2008 and 2017. Main outcomes were death, thyroid disease, non-thyroid autoimmune disease, and infection.

Results

We identified 132 alemtuzumab and 139 AHSCT-treated patients, together with 2486 matched patients treated with non-induction therapies. Four patients in the alemtuzumab group died (incidence rate [IR] per 1000 person years=8.6, 95% confidence interval [CI]=2.3-22.0) compared to one patient in the AHSCT group (IR=1.7, 95% CI=0.0-9.6) and a mortality rate in the reference group of 0.7 (95% CI=0.3-1.3). Thyroid disease was most frequent in the alemtuzumab group (IR=109, 95% CI=75-154), but also occurred more often for AHSCT (IR=34, 95% CI=18-56) compared to the reference (IR=5.3 95% CI=3.9-7.1). The incidence of non-thyroid autoimmune disease was similar in all groups. IR for infection occurring ≥6 months from therapy initiation was 53 (95% CI=30-87) for alemtuzumab, 108 (95% CI=75-150) for AHSCT, and 51 (95% CI=46-57) for the reference.

Conclusions

We confirmed a high incidence of thyroid disease in alemtuzumab- and to a smaller extent also AHSCT-treated patients, and found a higher incidence of infections for AHSCT compared to both alemtuzumab and non-induction therapies. Interestingly, the incidence of first-ever non-thyroid autoimmune events was similar between the groups. Disorders relating to reproductive organs and fertility were common in the AHSCT group, especially in females. Other adverse events were rare. Overall mortality was slightly higher in the alemtuzumab group, but only one of the four deaths was clearly linked to the treatment.

Background

Multiple Sclerosis (MS) is a chronic inflammatory disease characterized by autoimmune attack and destruction of myelin and neuroaxonal degeneration in the central nervous system (CNS). Previous reports have indicated that widespread differences in DNA methylation between MS cases and healthy controls in B cells. Importantly, B cells have come under renewed interest due to the effectiveness of treatments that deplete B cells, such as rituximab.

Objectives

To characterize epigenetic changes and their functional consequences in CD19⁺ B cells from MS patients, and to investigate changes in CD4⁺ T cells and CD14⁺ monocytes following B cell depletion with rituximab.

Methods

We measured DNA methylation in CD19⁺ B cells sorted from peripheral blood from relapsing-remitting (RRMS) (n= 26) and healthy controls (HC) (n = 15), which we compared and integrated with previously analyzed cohort (RRMS n = 12, HC n = 10). We also quantified DNA methylation in CD4⁺ T cells (n = 17) and CD14⁺ monocytes (n = 17) sorted from peripheral blood at baseline and 6 months of rituximab treatment. DNA methylation was measured using Infinium HumanMethylationEPIC arrays. Rituximab results were compared with results from a dimethyl fumarate treated cohort.

Results

Meta-analysis of the two B cell cohorts revealed 3 003 differentially methylated CpGs between RRMS and HC (with adjusted p-value < 0.05). Pathway analyses of the cohorts implicated dysregulation of genes involved in cell-to-cell communication, cell migration and activation. Rituximab treatment did not yield genome-wide significant changes in DNA methylation in CD4⁺ and CD14⁺ cells likely due to the indirect action of the drugs. Nevertheless pathway analysis of candidate differentially methylated CpGs associated with changes in activation immune activation, subset differentiation and motility being affected by B cell depletion.

Conclusions

Our data establish that B cells from MS patients acquire a distinct epigenetic profile connected to changes in pathways of importance for B cell functions. Furthermore, we demonstrate changes in other cell types following B cell depletion as a therapeutic modality.

Background

Multiple Sclerosis (MS) is a chronic inflammatory disease of a yet unknown cause characterized by autoimmune destruction of myelin and neurons in the central nervous system. Immune cells from the cerebrospinal fluid (CSF) can provide valuable insight into the pathogenic processes occurring in the typically inaccessible target organ; however, they have not been sufficiently utilized due to low numbers. DNA methylation is an epigenetic modification that without altering the genetic code can stably change the expression of genes and thus may play an important role in MS development. Moreover, due to stability, high specificity and the ability to be measured in limited amounts of material genome-wide, methylation changes may assist in studying MS pathogenesis.

Objectives

We aimed to establish and optimize a genome-wide methylation approach to investigate methylation changes that render immune cells pathogenic in MS with the prospect of better understanding disease pathogenesis.

Methods

Cells from the CSF of relapsing-remitting MS (RRMS n=5) and age- and sex-matched non-inflammatory controls (NINDC n=5) were extracted. Whole-genome bisulfite sequencing (WGBS) libraries were generated using the post-bisulfite adaptor tagging (PBAT) protocol, which originally was designed for single-cell and adapted to the limited cell amount as previously described (1). Results were replicated in a larger cohort (RRMS n=18 and NINDC n=7), while the reliability of the methodology was confirmed with technical replication of the original cohort.

Results

We first explored the global landscape of CpG methylation levels, as well as specific genomic features including promoters, enhancers and CTCF binding sites. We conducted statistical analysis based on three distinct methods, which identified differentially methylated CpG (DMCs). Methylation levels calculated in the sequencing data were well correlated with the independent technical replicates where the sequencing depths were comparatively lower which gave more evidence the less sequenced data can reflect the true values to some degree. Besides, in the replicate sample groups, a large proportion of DMCs changed in the same direction when applying a minimal 0.2 difference. Moreover, NFATC1, NFKBID, MAPK1, MAP2K2 and other genes participated in the regulation of the immune response were differentially modified. In addition, the differentially modified genes were significantly enriched in pathways including integrin signaling pathway which is important for cell movement and activation, CD40 signaling pathway which is related with the lymphocyte activation, as well as various cytokine signaling pathways such as IL-1, IL-6, IL-17.

Conclusions

Genome-wide methylation analysis, based on a low cell-number library preparation, will enable us to study MS pathogenesis using samples that are difficult to comprehensively study by many other methods.

Background

Multiple sclerosis (MS), a chronic disabling disease requiring long-term treatment and regular monitoring, is associated with negative effects on health-related quality of life (HRQoL). CLARIFY-MS (NCT03369665) aims to assess the impact of cladribine tablets (CT) 10 mg (3.5 mg/kg cumulative dose over 2 years; CT3.5) on HRQoL and treatment satisfaction in patients with highly-active relapsing MS (RMS).

Objectives

To present an interim analysis of CLARIFY-MS at 6 months after initiating treatment with CT, assessing treatment satisfaction through the Treatment Satisfaction Questionnaire for Medication (TSQM) v1.4 and safety through the collection of safety assessments in highly-active RMS patients.

Methods

CLARIFY-MS is an ongoing phase IV, open label, single arm, multicenter, 2-year study. Patients with RMS received CT3.5, with 2 weeks of active treatment per course (week 1 and 5 of each year). TSQM v1.4 was used to assess patient-reported treatment satisfaction (a score of 100 is the best possible rating). The TSQM measures 14 items across four domains: effectiveness (three items), side effects (five items), convenience (three items), and global satisfaction (three items).Treatment-emergent adverse events (TEAEs), serious adverse events (AEs), and lymphocyte counts were recorded.

Results

Treatment satisfaction: Of 554 patients screened, 482 received CT. The age and Expanded Disability Status Scale adjusted global treatment satisfaction score (95% confidence interval) at Month 6 was 70.0 (66.6–73.5). Treatment-experienced patients (prior treatment with disease-modifying drugs [DMDs]) reported similar treatment satisfaction scores to DMD-naïve patients (70.2 vs 68.7). At Month 6, >75% of patients rated the TSQM side effects score with 100. The mean side effects score was 91.9, mean convenience 86.6. Safety: 275 patients (57.1%) experienced ≥1 TEAE after drug initiation, most commonly headache and lymphopenia. Most post-baseline lymphopenias were of grade 1-2; 33 patients (6.8%) experienced grade 3 lymphopenia and no grade 4 lymphopenia was observed.

Conclusions

This interim analysis of CLARIFY-MS found that at 6 months, patients were generally satisfied with CT treatment. The convenience of CT treatment and side effect profile were especially important to patients. Safety results at 6 months post-treatment are consistent with the known safety profile, with no new emerging safety signal; most lymphopenias were grade 1-2.

Background

Background: The envelope protein of the human endogenous retrovirus type W (HERV-W ENV) is expressed in chronic active MS lesions. Preclinical models have shown that HERV-W ENV activates microglia, prevents maturation of oligodendrocyte precursor cells, and leads to neuronal death. Following the effects of a B-cell depleting, anti-inflammatory therapy, rituximab (RTX), with temelimab (TML), a humanized, IgG4-κ monoclonal antibody against HERV-W ENV represents a novel therapeutic approach against neurodegenerative features of MS.

Objectives

Objective: To present safety preclinical results on the interaction of RTX and TML, and the trial design of the ProTEct-MS study.

Methods

Design/Methods: Interactions between RTX and TML were studied in vitro in high density-peripheral blood mononuclear cells (PBMCs) and ex-vivo in a whole blood loop system from fresh human blood.

ProTEct-MS is a randomized, double-blind, placebo controlled, parallel group study. Enrolment commenced in 2020/6 and will be completed in 2020/12. Patients with RMS (2017 McDonald criteria) (N=40) being previously treated for ³12 months with RTX are randomized (1:1:1:1) to monthly iv TML (18, 36 or 54mg/kg) and placebo for 48 weeks.

Eligibility criteria: age 18-55 yrs, Expanded Disability Status Scale (EDSS) of 2.5-5.5 at screening; clinical worsening in ³1 neurological domain as assessed by EDSS, 6MWT or T25FW, or cognitive functioning as assessed by SDMT over the last year.

Primary objective: assessment of safety and tolerability of TML

Secondary outcome measures: MRI: change of brain atrophy, lesion volume and magnetization transfer ratio

Results

Results: Co-administration of TML with RTX was overall comparable to vehicle for all blood parameters assessed including cytokine levels of all five donors tested in both in vitro and ex-vivo assays. Co-administration of TML with RTX did not affect the functionality profile of either compound. By September 2020, 25% of patients are expected to be randomized, providing baseline clinical and MRI characteristics.

Conclusions

Conclusions: Preclinical safety experiments of the drug combination showed no evidence against the use of TML following RTX in humans. ProTEct-MS study patients represent a RMS cohort with progression in absence of relapse activity (PIRA,) i.e. whose present clinical condition is stable under RTX therapy, enabling TML's effects on attenuating mechanisms of progression to be measured without interference by acute inflammatory activity.