Risk factors for multiple Sclerosis

D'hooge MB, Nagels G, Bissay V, De Keyser J .  Modifiable factors influencing relapses and disability in multiple sclerosis. Modifiable facors influencing  relapses and disability in multiple sclerosis.  Multiple Sclerosis 2010; 16: 773-785.

Review paper.
Strong evidence suggest relapses can be triggered by infections, the postpartum period and stressful life events.  Hormone fertility treatment may trigger relapses.

Disease progression may occur due to stressful life events,radiotherapy to the head, low levels of physical activity and low vitamin D levels.  Smoking affects disease progression clinically and by MRI.  TNF inhibitors induce exacerbation.  GCF colony stimulator factor for stem cells induces worsening in 4/10 patients. Add on statin to Betaseron may trigger relapses, larger trial is underway.

Vaccinations against influenza, tetanus and hepatitis B appear safe as are surgery, general and epidural anesthesia, and physical trauma. 

Associations with lower relapses include pregnancy, exclusive breastfeeding, sunlight and higher vitamin D exposure. 

Childbirth does not increase relapse rate.  Protective effect of ETOH remains to be confirmed. 

Re: [seMSc] Case - Gilenya

Please be aware of this paper:

 

Espinosa PS, Berger JR.  Delayed fingolimod associated asystole.  Multiple Sclerosis 2011; 17:1387-9.

 

A patient with MS developed asystole and sustatined bradycardia 21 hours after the first dose of fingolimod.  Patient was a 20 yo male with no prior treatment with DMT's, no personal or family history of cardiac disease.He had mild mental retardation and was taking risperidone.  He received IVMP and on day 4 began fingolimod.  The period of asystole lasted only seven seconds, was associated with brief LOC and convulsive like activity and was captured.  He remained bradycardic for two more days.  The f. was discontinued.  Authors suspect a synergistic response between fingolimod and risperidoneand possibly other psychotropic medication.

Early onset natalizumab related PML

Multiple Sclerosis 2011; 17: 1397-98 (letter)

 

23 year old with MS with EDSS of 5, failed GA, then azathioprine, then natalizumab.  After 6 doses he developed ataxia and was diagnosed with PML, confirmed by CSF. 

2 minute walk test in MS

Gijbels D, Eijnde BO, Feys P.  Comparison of the 2 and 6 minute walk test in multiple sclerosis.  Mulitple Sclerosis 17: 1269-72, 2011.

 

Authors state the shorter 2mwt is a practical alternative to the standard 6mwt in a disabled population.  40 subjects with MS, mean EDSS of 3.5, some walking with a cane, and analysis showed 2mwt was within 5 +/- 4 % of 6mwt.  Authors believe can substitute 2mwt for 6mwt based on results.

Components of Rao's brief repeatable battery of Neuropsychological tests

BRBNT

 selective reminding test

Spart- Spatial recall test

PASAT/SDMT

World List Generation

 

multiple forms used

 

also can be used with

Stroop

MADRS (depression scale)

FSS

 

Natalizumab v. Interferon Beta head to head study

Natalizumab vs interferon beta 1a in relapsing-remitting multiple sclerosis: a head-to-head retrospective study; Lanzillo R, Quarantelli M, Bonavita S, Ventrella G, Lus G, Vacca G, Prinster A, Orefice G, Tedeschi G, Brescia Morra V; Acta Neurologica Scandinavica (Nov 2011)

Background -  No head-to-head study has been performed yet to assess whether natalizumab is more effective than classical immunomodulators in multiple sclerosis (MS). Aim -  To retrospectively compare the efficacy of natalizumab vs IFN beta 1a SC (44 μg; Rebif(®) ) on clinical and radiological findings in two matched cohorts of patients with MS. Patients and methods -  We retrospectively enrolled two cohorts of 42 patients (F/M: 35/7) with relapsing-remitting multiple sclerosis treated with natalizumab or IFN beta 1a for at least 12 consecutive months. Outcome measures were annualized relapse rate (ARR), changes in expanded disability status scale (EDSS) score, and number of contrast-enhancing lesions (CELs) at magnetic resonance imaging (MRI). Results -  In both groups, the ARR in the 12 months of treatment was lower than in the 12 months before therapy (0.24 vs 1.50 in natalizumab-treated group, P < 0.0000; 0.55 vs 1.10 in IFN beta 1a-treated group, P = 0.0006), being the effect of natalizumab significantly stronger (P = 0.0125). EDSS reduction was significantly different between the two groups in favor of natalizumab (P = 0.0018). The frequency and number of CELs per patient were decreased in both groups. In the second year, the treatment affected ARR and EDSS progression in the two groups of patients similarly to the first year, whereas number of CELs decreased more significantly in natalizumab group (P = 0.008). Conclusions -  After 12 and 24 months of therapy, natalizumab was more effective than IFN beta 1a SC on both disease activity and disability progression. Prospective head-to-head studies would be helpful to further evaluate the differences observed in the MRI outcomes.

GLANCE trial

Goodman A et al.  GLANCE : Results of a phase 2 randomized double blind placebo controlled study.  Neurology 2009; 72:806-812.

Study adding Tysabri to glatiramer-- safety trial.  Results showed increased natalizumab antibodies, but safe otherwise.  Efficacy was much better in combination group than in the GA alone group re MRI.  110 patients were randomized, half got GA + placebo, others GA + NAT.  Took patients with active disease year before entry.

NABs and Steroids-- the Mayo Clinic critically appraised

Zarkou S., et al. I Dean Wingerchuk)  Ar corticosteroids efficacious for preventing or treating neutralizaing antibodies in multiple sclerosis patients treated with Beta interferons?  A Critically appraised topic. The Neurologist 2010; 16: 212-214.

Bottom line-- idea of using steroids in any scenario for Nabs is based on dubious evidence.

Outcomes among natalizumab patients acquiring PML

Vermesch P et al.  Clinical outcomes of natalizumab - associated progressive multifocal leukoencephalopathy.  Neurology 2011; 76:1696-1704

Authors analyzed 35 patients with PML related to natalizumab.  25 survived.  Survivors had lower age and EDSS on mean, and shorter time to diagnosis of PML.  86 % had unilobar or multilobar disease on initial PML brain MRI, whereas 70 percent of fatal cases has widespread disease on MRI.  Disability scores (Karnofsky scale) among survivors was highly variable.  16/36/48 % respectively had mild, moderate or severe disability.

Tidbits
Almost all patients withdrawn from natalizumab got IRIS and were treated with i-c corticosteroids, in addition to plasma pheresis to removed natalizumab.  They also received mirtazepine or mefloquine due to in vitro studies showing an effect on replication. 

Tables show much less nonfatal PML in US v. Europe.  Rate of nonfatal to fatal PML was, US: 3:8 in Europe 22:2.  This is not discussed but I wonder if more nonfatal PML slips through cracks in US  and is either not diagnosed or reported. 

Posterior fossa PML was rare.  Most patients had enhancing lesions.

Vitamin D and African Americans with MS

Gelfand JM, Cree BAC, McElroy J et al.  Vitamin D in African Americans with Multiple Sclerosis.  Neurology 2011; 76:1824-1830. 

339 African American MS patients and 342 controls were compared.  MS patients had lower vitamin D levels than controls, but the lower levels did not affect disease severity.  The differences were explained by geography and climate, as well as ancestry. 

Natural history of MS relapses

Bejaoui K, Rolak L.  What is the risk of permanent disability from an MS relapse?  Neurology  2010: 74: 900-902.

Authors review >2500 relapses and find only 7 with relapse with EDSS >6 that did not recover. 2 of those were on interferons at the time.  Two had a presentation of tumefactive MS.  They concluded that the fear of sudden irreversible disability should not affect treatment decisions. 

4 aminopyridine toxicity mimicking autoimmune limbic encephalitis

Neurology 72; 2009: 1100-1101

A 22 year old man ingested 30 tablets of 4-AP. He was agitated but oriented, flushed, mildly febrile, hypertensive.  EEG showed spikes and polyspikes and waves. CSF was normal.   MRI showed bitemporal hyperintensity on T2 imaging as well as affecting anterior cingulum.  Cardiac EF initially was 24 % but recovered.  He awoke to be mute and amnestic.  He recovered over one year but still had short term memory problems.   

differential diagnosis of long segment myelopathy suggesting NMO

Compression/ spondylitic myelopathy-- pearl- check enhancing scan for signet ring sign 

zoster myelitis-- history of shingles

paraneoplastic-- history of cancer

infective-helminth-- prior "Wells" syndrome, with eosiniphilia

cord AVM- history of worsening with Vasalva, singing, defecation, also check blood sensitive sequences and MRA cord

Sjogren's-- controversial, check CSF NMO as well as serum

B12 deficiency-- posterior cord

copper deficiency-- also posterior cord

stroke-- can affect almost any part of cord

multiple sclerosis/transverse myelitis-- check brain MRI

GBS/CIDP-- may be difficult to differentiate clinically, check nerve roots for radiculitis on MRI

CMV radiculitis -- in immunocompromised

Behcet's

betaseron pregnancy registry

www.betaseronpregnancyregistry.com

 

phone 800-478-7049

 

less than 100 people enrolled, 85 births

Pearls about natalizumab and PML

1.  PML appearance in natalizumab cases may include enhanced lesions and even ring enhancing lesions unlike HIV associated PML

 

2.  JC virus must be ordered as ultrasensitive assay as routine assay limit of sensitivity is around the fifty percentile of the (low) number of copies seen in some cases of Tysabri associated PML

 

3.  PML presentation can be any type of new neuro abnormality including aphasia, heimparesis, hemisensory loss and others.

 

4.  PML cases increase with Tysabri exposure up to two years but is not clear about more than two years.  Prior immunosuppressive therapy increases the risk of PML

 

5.  IRIS occurs after removal of natalizumab with sometimes precipitous decline in patient's status and even death.MRI usually shows GD+ enhancement, within 1-6 weeks after removing natalizumab.

 

6.  IRIS prevention is reason for using Solumedrol one gram iv per day for five days followed by long taper

Simvastatin for SPMS is recruiting

The MS-STAT trial: a phase II trial of high-dose simvastatin for secondary progressive multiple sclerosis: baseline trial profile; Chataway J, Anderson V, Chan D, Frost C, Hunter K, Kallis C, Greenwood J, Schuerer N, Alsanousi A, Nicholas R; Journal of Neurology, Neurosurgery, & Psychiatry (JNNP Online) 81 (11), e55 (Nov 2010)

Background Therapeutic options for secondary progressive MS (SPMS) are very limited. Simvastatin is an attractive drug with potentially anti-inflammatory (e.g., reducing leukocyte migration) and neuro-protective effects (e.g., up-regulation of the major cell survival protein bcl-2), in addition to being well tolerated. In trials of early stage MS it is undergoing trials as a single agent or in combination therapy with standard disease modifying treatments. This is the first trial in SPMS. Trial Overview Double-blinded/placebo-controlled (1:1) with 80 mg of simvastatin. Two-year follow-up. Entry EDSS 4.0-6.5. Brain atrophy rate as determined from T1-weighted volumetric MRI using the brain boundary shift integral is the primary outcome measure. Secondary outcomes include disability scores, neuropsychological assessments and immunological profiling. Results 408 patients were referred, 203 screen failures, 140/140 patients were randomised. Age 52 years (range 35-65), 68% female, MS duration 21 years (8) with a secondary progressive phase of 13 years (7). Median EDSS 6.0 (IQR 0.5). MSFC 10 m walk/s 23.6 (25.6); Nine-hole peg test/s 34.6 (13.2); PASAT/60 35.3 (14.2). MSIS-29ver 2.0 scores: physical 49/80 (11), psychological 20/36 (8), total 69/116 (14). All data as mean (SD) unless stated. Conclusion This trial is fully recruited and will report in late 2011. ClinicalTrials.gov, number NCT00647348.

Testing for Vitamin D Pearls

Kennel KA et al. Vitamin D deficiency in adults : when to test and how to treat.  may Clin Proc 2010: 85; 753-758

1.  Terminology:  D2 = ergocalciferol is obtained from vegetables and oral supplements.  D3= cholecalciferol is obtained from UVB sunlight, oily fish and some fortified foods such as milk and bread.  25 (OH) D= calidiol, contains D2 and D3.  1,25 (OH)2D= calcitriol and is converted in kidney and other tissues by the one alpha hydroxylase gene. 

2.   Deficiency is caused by lack of exposure to sunlight, dietary deficiency or malabsorption.  Measuring calcidiol is best measurement of body stores of 25 (OH) D total vitamin D and is best test for deficiency, whereas 25 (OH)  D  D2 and D3 is useful for monitoring to detect noncompliance, or malabsorption. In general the D content of food is low, and D levels come from sunlight and supplements.

3.  1,25 (OH)D can be falsely normal in vitamin D deficient patients due to hyperparathyroidism and thus should not be measured.

4.  Reference ranges may vary based on geographic location, season, ethnic background, age. 

5.  Vitamin D toxicity has never been reported with a level less than 80, and usually requires over 140.   Fear of toxicity is overblown.  This is because calcitriol, the renal 1,25 OH D, feedbacks directly limiting its production via 24 hydroxylase gene.  Calcitriol also feeds back on the PTH gene.  The alternative result is inert metabolites of Vit D, including 24,25 calcidiol and 1,24,25 calcitriol.

6.  Used but not clinically validated for severe Vitamin D Deficiency:  loading dose of 50,000 weekly for 2-3 months, or tiw for one month.  A minimum total dose of 600,000 iu predicts increasing the level to normal (>30).  A lower dose is used for moderate deficiency.  Maintenance of 800-2000 iu is needed to prevent slideback. 

7.  Powder D3 does NOT clog feeding tubes unlike D2. 

Motor cortex stimulation for pain in multiple sclerosis

Motor cortex stimulation for intractable neuropathic facial pain related to multiple sclerosis; Tanei T, Kajita Y, Wakabayashi T; Neurologia Medico-Chirurgica (Tokyo) 50 (7), 604-7 (2010)

A 33-year-old man presented with ongoing severe right facial pain and sensory disturbances caused by multiple sclerosis (MS). Neuroimaging demonstrated demyelinating lesions in the right dorsal pons and medulla oblongata. The pain was refractory to carbamazepine at 800 mg/day, gabapentin at 1800 mg/day, morphine at 30 mg/day, amitriptyline at 60 mg/day, and diazepam at 4 mg/day, along with twice-monthly ketamine (60 mg) drip infusions. The patient underwent motor cortex stimulation (MCS), resulting in>60% pain relief, reduction in the required doses of pain medications, and discontinuation of ketamine administration. MCS is effective for MS-related neuropathic facial pain.

 

Successful Management of Natalizumab-Associated Progressive Multifocal Leukoence

Schröder A, Lee DH, Hellwig K, Lukas C, Linker RA, Gold R; Archives of Neurology (Jul 2010)OBJECTIVE: To describe a case of successful clinical management of natalizumab-associated progressive multifocal leukoencephalopathy (PML) and immune reconstitution syndrome (IRIS) in a patient with multiple sclerosis. DESIGN: Case report. SETTING: University hospital. Patient A 41-year-old woman with relapsing-remitting multiple sclerosis developed PML after 29 natalizumab infusions. INTERVENTIONS: Immediate plasma exchange was combined for removal of natalizumab with application of mefloquine and mirtazapine to limit viral replication and oligodendrocyte infection. A subsequent IRIS was treated with glucocorticosteroids. RESULTS: After 3 months of treatment, cerebrospinal fluid tested negative for JC virus. There was a favorable outcome, and the Expanded Disability Status Scale score remained stable at 3.5 compared with before PML. CONCLUSIONS: In the setting of early diagnosis and consequent treatment, natalizumab-associated PML can be well managed in some cases. This situation differs from the course of PML in other conditions, eg, after the application of depleting monoclonal antibodies, in which irreversible cellular effects are associated with very high mortality.

MACFIMS- cognitive assessment for multiple sclerosis

Benedict R.  Minimal neuropsychological assessment of MS patients.  The Clinical Neuropsychologist 2002; 16:381-397.

Contains tests with alternate forms and test-retest capability. 

Processing speed/Working memory

PASAT
Symbol Digit Modality Test (SDMT)  equally good as PASAT as standalone

Learning and Memory

CVLT-II
Brief Visuospatia Memory Test- Revised

Executive Functions

D- Kefs Sorting Test- sorting cards, Trails, Tower, Design Fluency, Stroop

Visual perception/Spatial Processing

Judgment of Line Orientation

"Language"

Verbal Fluency (COWAT)

Non Macfims-- office assessment
Attention:
1 trial PASAT
Trails (public domain)
Mental control (days forward, backwards, serial 7's)
Cancellation test (public domain)

Memory:
list learning, 10 common, easy, unrelated words, 3 trials, 20 minute delay with recognition trials (yes/no)

Language:

5-10 pictures use for each patient
COWAT equivalents (CFL, PRW, FAS)
semantic category fluency

Motor coordination/processing speed:
9 hole peg
Trails A
SDMT written and oral (public domain)

Subjective:

Multiple sclerosis neuropsychological questionnaire (Benedikt et al., 2004)
15 items, MSNQ

Benign MS and cognition

Portaccio E, Stromillo ML, Goretti B, et al (last author Stefano) .  Neuropsychological and MRI measures predict short term evolution in benign multiple sclerosis.

Consensus for definition of b-MS is those who are fully functional after ten years.  Different systems are used to classify patients.  Authors defined as EDSS < 3 after 15 years of disease duration. 

Authors used Rao BRB and added Stroop test, using a cutoff as 2 SD's below Italian normals.  Patients with 3 or more test failures were classified as cognitively impaired.  Tests included SRT, SPART (spatial recall, 10/36 cutoff), PASAT, SDMT, WLG, Stroop. 

Authors followed patients at a mean of five years, using "still benign" measure.  Disability was EDSS>4, or increase of 1.5 if starting EDSS was zero, or increase of >1 point if starting EDSS was > 1 confirmed at six months.  31.8 percent of patients with "b-MS" were impaired at baseline cognitively.  Additional 16 % failed one test and 19 % failed 2 cognitive tests at baseline.  At followup, 43 % had EDSS progression of one or more points, confirmed.  18 % became "no longer benign," or "NLB."  NLB subjects had more relapses during followup period, but not in year before, and related to male gender and number of tests failed. Also baseline T1 lesion volume was predictive. 

editorial
Benedict RHB, Fazekas F.  Beningn or not benign MS: a role for routine neuropsychological assessment?  Neurology 2009; 73: 494-495.  Authors mention BRB and MacFims, each having alternate forms that permit repeat testing every 2-3 years. 

Cortical lesions and atrophy associated with cognitive impairment in RRMS

Calabrese M, Agosta F, Rinaldi F, et al. (last author Filippi).  Arch Neurol 2009; 66:1144-1150.

Authors studied 70 patients with multiple sclerosis and 22 normal controls .  They used the Rao BRB and used a cutoff of 2 SD's below mean on at least one test of, version A of BRB to define cognitive impairment.  They also looked at T2 lesion volume, contrast enahncing lesion number, cortical lesions using double inversion recovery sequences, volume, and normalized grey matter volume.  Finding was that T2 lesion number and enahncing lesions were not important, but that cortical lesions, cortical and brain volume and gray matter involvement predicted cognitive impairment. 

Tests used in BRB were"  SRT and delayed recall, spatial and delayed recall (10/36 cutoff), PASAT 3 and SDMT, and word list generation.  See Camp et al, Brain, 1999 for normative values. (see article anyway). 

24 patients were listed as cognitively impaired.  The rate of impairment was, for SRT delayed, 12.9%; PASAT and word generation 10 %, SDMT 8.6 %, EDSS also predicted. 

Authors discussed the "cognitive impairment index" as discussed in Brain article above.  This is a continuous variable obtained by a grading system applied to each patient's score on each test, depending on number of SD's below mean normal.  Grade 0 means index was above mean for normal controls.  Grade 1 was given for mean to 1 SD below normal.  Grade 2 was 1-2 SD's  below normal.  Grade 3 was given for more than 3 standard deviations below.  The results for all tests were added to give an overlal measure of cognitive dysfunction.

Authors discussed that the CL (cortical lesion) number and volume correlated with CI index score, and deficits in attention, concentration, speed of processing, and memory. 

Neuropsychological effects of interferons

Fischer JS, Priore RL, Jacobs LD et al.  Neuropsychological effects of interferon B-1a in relapsing multiple sclerosis.  Neurology 2000; 48: 885- 892.

Study looked specifically at Avonex to 166 patients 104 weeks apart.  The neuropsych battery was divided into Set A (information processing and learning/memory) ,  Set B ( visuospatial and problem solving), and Set C (verbal abilities and attention span).  Avonex benefitted A set, with a trend in B set and no effect on C.  Secondary analysis showed a treatment effect on time to worsening with PASAT. 

Subject selection-- disease duration at least one year, at least 2 relapsed in 3 years, and EDSS 1-3.5 inclusive.  age 18-55. Study was placebo controlled.  Actual tests used were , for Set A, signnificant group, CalCap Sequential reaction time (information processing), Ruff Figural Fluency Test error ratio, and CVLT Trials 1-5 (total).

Set B tests were WMS-R Visual Memory Span (forward), WCST perseverative responses, visual search number of trials, TOL % planning time. 

Set C tests were WAIS-R information, and digit span forward.

Secondary outcomes were RFFT error ratios, RFFT unique designs, CVLT trials 1-5 (total), PASAT processing . 

Results-- on set A, the CVLT test was most important.  On Set B, Tower of London was most important.  Set C was negative tests.  In secondary outcomes, slopes were correct direction in all variables, RFFT appeared significant, and  practice effects were noted in all groups. 

Authors contrast to 2 other studies of cognition with treatment for MS.  One was a copaxone study (Weinstein et al, Arch Neurol, 1999) which was negative, and one was for Betaseron, that showed an effect for visual memory  (Pliskin et al, Neurology, 1996).  However, neither of those was as good of a study. 

MIMS Study for Novantrone in MS

Hartung H-P et al.  Mitoxantrone in progressive multiple sclerosis: a placebo controlled, double blind randomised multicentre trial.  The Lancet 2002; 360: 2018-2025.

194 patients with worsening RRMS or SPMS were given MTX or placebo  q 3 months for 24 months (5 mg/meter squared).  at end, the treated group had a benefit in five clinical primary outcome measures:  change in EDSS, change in ambulation index, adjusted total number of treated relapses, time to first treated relapse, and change in standard neurological status. 

Shortened version of PASAT is effective discriminant in MS

Solari A, Motta A, Radice D, Mendozzi L.  A shortened version of the PASAT 3 is feasible.Multiple Sclerosis 2007

Authors studied PASAT in 105 persons with multiple sclerosis and controls using PASAT 3 regular and shorrtened version.  They used the first 20 items.  The first 20, 30 and 50 items of the PASAT 3 retained discriminant value for MS

Notes study did not norm for age (highly sensitive) or practice effect (important). 

Note:  A review of the PASAT Tombaughh TN Arch Clin Neuropsychol 2006; 21:53-76.

Effect of copaxone on fatigue in MS

Metz IM, Patten B, Archibald CJ et al.,The effect of immunomodulatory treatment on multiple sclerossi fatigue.  JNNP 20 04; 75: 1045-7. 

In Calgary 218 MS clinic studied patients with initially comparable levels of fatigue who were treated with glatiramer (copaxone) v. interferons using fatigue impact scale.  2x as many started on copaxone and 2x as many reported greater reductions in fatigue.  This was true for all MS patients and RRMS patients.  The difference affected total FIS, the physical and cognitive subscale but not the social subscale.  The authors used one SD as the cutoff. 

Cognitive dysfunction in patients with CIS or newly diagnosed MS

Glanz BI, Holland CM, Gauthier SA et al.  Multiple Sclerosis 2007; 13:   senior author Howard Weiner BWH

Authors studied 92 patients with CIS/new MS and fouund 49 % impaired on one or more tests of the battery.  There was not correlation with MRI measures of disease including T2 lesion volume, NAWM, grey matter volume or brain parenchymal fraction.

Tests given were Rao's brief repeatable battery including SRT, 10/36 Spatial Recall test, SDMT, PASAT, COWAT, CES Depression Scale.  PASAT, SDMT, and SRT were the clear tests that showed abnormalities in MS v healthy controls. 

Authors contrast their results to Achiron and Barak (JNNP 2003) who found visual learning and recall , COWAT and SDMT to be most abnormal tests.  Other studies were Feinstein (Brain, 1992; 115: 1403-15) and Callanan MM et al (Warrington) Brain 1989; 112: 361-74.   

main references for Zamboni procedure for MS

• Zamboni P, Menegatti E, Salvi F, et al. Intracranial venous haemodynamics in multiple sclerosis. Curr Neurovasc Res 2007;4:252–258.




• Zamboni P, Galeotti R, Salvi F, et al. Chronic cerebrospinal venous insufficiency in patients with multiple sclerosis. J Neurol Neurosurg Psychiatry 2009;80:392–399.



• Zamboni P, Galeotti R, Salvi F, et al. Endovascular treatment of chronic cerebrospinal venous insufficiency: A prospective open-label study. J Vasc Surg 2009; 50:1348–1358.

Q & A AAN 2010

COMMENTS
1.  possible association of seminoma and demyelination disorder
2.  dural av fistula lesions identified by stepwise progression and involvement of conus, angiography can miss it
3.  Rabies case of Weinshenker-- rabies is increasing in bat population, catch the bat, give everyone a shot even if they don't have a bite, only have a week or so to get a shot
4.  NMO CSF may be positive with negative serum studies, but is rare.  Antibody arises in blood and leaks into CSF, does not get produced in CSF.  Could be a question of CSF is cleaner with less noise of other antibodies in blood interfering with test.
5.  Persistent black holes at onset is a good sign of non-ADEM; rarely if ever seen all enhancing lesions with ADEM more common to see none of lesions enhance.

Superficial siderosis

check 2009 article Neurology

check cerebellar folia
do myelogram look for extradural defect
consider fixing it

ADEM and atypical demyelinating disease pearls

1. Occurs more in childhood than adulthood
2.  Occurs post infection, infection may include VZV, EBV, HSV 6, measles, influenza
3.  Acutely, all lesions enhance rather than being of different ages (MAY occur)
4.  Pathologically perivenous inflammation with very little tissue or axonal destruction
5.  Hurst's hemorrhaghic leuokoencephalitis is sometimes considered as part of spectrum of ADEM, with severe course, may be fatal, hemorrhage may be petechial, with pathological and MRI diagnosis and severe demyelination
6.  Marburg's MS -- severe and unrelenting MS even within one year. Otto Marburg, 1906
7.  Tumefactive MS--may be monophasic course or develop into MS, typical or otherwise
8.  Balo's concentric sclerosis with concentric rings of demyelination alternating with remyelination, described 1927, variable course, more common in Southeast Asia, high level if inducible nitrous oxide synthase similar to hypoxia.
9.  Isolated optic neuritis without MS--half may not progress to MS without associated MS lesions
10  CRION chronic relapsing inflammatory optic neuritis disease is restricted to optic nerves
11.  NMO spectrum disease with isolated and recurrent optic neuritis

For above, treatment algorithm is five days of solumedrol, then plasma exchange (at Mayo Clinic) then cytoxan.

Weinshenker on Acute Myelopathies from AAN 2010 pearls

1.  Most myelopathies are undetermined cause at initial diagnosis, then infectious, then CVA, then systemic disease eg. lupus

2. NMO may have a central cord syndrome

3.  Initial functinal score and a central lesion on MRI are predictors at outcome, as is systemic disease or NMO at outcome.

4.  Paraneoplastic case with CRMP 5 in a 42 year old man with positive vep, cigar shaped faintly enhanicng lesions improved with removal of papillary thyroid cancer.  One radiographic sign not well known is owl eye sign with 2 "eyes"  suggests cancer or paraneoplastic.

5.  Cord compression can produce abnormal signal mimicking transverse myelitis clue check axials, and clinically symptoms did not progress over 3 weeks. Signet ring pattern of enhancing signal is c/w compression

6.  Case zoster leading to myelitis indistinguishable from NMO by MRI abnormalities.  Infections that cause acute myelopathy include:  Schistosomiasis (esp in Mideasterners), rabies virus, TB, lyme, syphilis, HSV, VZV, West Nile Virus, dengue, polio, coxsackie and Echovirus, actinomyces, blastomyces, >50 % none found, MAY HAVE OCB's

7. 71 yo woman with recurrent TM after 6 months, then paratonic spasms, TPO antibodies, letm, was NMO

8.  ADEM can be NMO positive and turn out to be NMO


Summary- conclusions  Algorithm: 1) is it compressive (subtle types included such as lipomatosis, spondylosis)  2)  is it really a myelopathy (parasagittal meningioma, CIDP)  3)  is it an acute presentation of a metabolic disorder (eg. B12 deficient patient exposed to nitrous oxide)  4) Is image quality and timing adequate?  (too early, too late)   5)  Is it functional?

New MRI Montalban criteria for diagnosis of multiple sclerosis

Neurology 2010; 74: 427-434.  called MAGNIMS proposal

* An MRI at any time showing dissemination in space (DIS) and showing 1 or more asymptomatic lesions enhancing and nonenhancing thus meeting criteria for dissemination in time (DIT) is sufficient to diagnose MS

*  An MRI showing DIS but without enhancing lesions, or with all lesions enhancing (thus no DIT), would require a new MRI to demonstrate additional lesions

*  An MRI at any time showing lesions but not DIT or DIS requires new MRI's

One DIS criterion: need one or more asymptomatic lesions in 2 of 4 locations considered characteristic for MS: juxtacortical (JC), periventricular (PV), infratentorial (IT), and spinal cord (SC).

Two DIT criteria:  1)  presence of one or more enhancing and nonenhancing lesions irrespective of the time of the scan and 2) presence of a new T2 and/or Gd+ lesion compared to a previous scan, irrespective of the time of the scan

The above apply only to those with CIS, ie symptomatic patients. 

fatigue components

Nocturnal jerks and phasic spasms
Nocturia multiple NGB
Depression
Deconditioning
increased energy requirements to move-- due to spasticity, balance
lots of drugs that contribute to fatigue
anemia
low vitamin levels, b12, D
temperature effects especially perimenstrual
effects of interferons. Try Naprelan, the long acting naprosyn, treximet,or pentoxifylline to prevent AE's before injections.

pearls symptoms management elliott froman

1. nocturia due to low compliance bladder-- consider DDAVP, urology eval to look at pelvic floor
2. always get urology exam to look at pelvic floor after you have gotten PVR
3. Phasic spasms are treated differently than tonic spasms or restless legs, try levitiracetam
4. check ferritin, not just in restless legs patients along with vitamin D, thyroid
5. fampridine flattens decay curve of temperature effects, fatigue
6. Vyvanse given for fatigue and cognitive slowing-- works.  hypertension uncommon but works
7.  4 AP the more truncal and postural instability, the likelier to respond to 4 AP
8.  Hold 4 AP if you have a fever, uti, sepsis due to risk of seizure
9. aceto L carnitine double effect of amantadine on fatigue, 2 nice studies, 1-2 grams bid buy bronson's vitamins online cheap, may even be able to go off provigil or amphetamines
10. tizanidine occassionally causes formed visual hallucinations not always require stopping drug, eg. "Indian shaman visiting her, like having a doctor at home"
11.  aerosolized ethyl chloride anesthetizes skin is best for injection pain.
12.  Neuropathic sensations after sensory myelitis, MS "hug" (aka anaconda sign), sharp burning rhythmic oscillating pain after defecation and sexual intercourse ("real neurologists do "heads and tails").  tried levitiracetam, it helped, think of phasic spasticity and saw dramatic benefit.  Thoracic squeezing continued clonazepam helped a little.  Used belladonna and opiate suprettes (b & o supp) completetely resolved defecation spasms.
13.  trigeminal neuralgia-- refractory-- suboccipital decompression first, then rhizotomy or gamma knife.  What are you decommpressing? Decompress but also scrape and cut trigeminal root. Decompression works better when done as first procedure.
14.  Causalgia on end of hand-- use topical compounded agents rather than systemic agents if topical and superficial-- compound almost any drug  GBN, mexilitene/clonidine/lidocaine
15.  Gait mechanics--swing limb advance is key causes toe drag, falling.   Medicare now pays for many walk aid and similar devices (fes- functional electrical stimulators).  prevent falls, decrease energy utilization
16.  poor hip thrust due to weak iliopsoas, clonus, tonic and phasic spasticity, tight gastroc,
17. genu encurvatrum (hyperextension of knee during standing) cure with AFO.  Dorsiflexion causes flexion of joint above.
18.  Edema-- everyone with weakness has it.  huge factor needs to be addressed buy at discountsurgicalstockings.com cheaply get 8-12 mm Hg "like a bilge pump" start at 15-20.  ten dollars a pair. leg is lighter and movement is aided not carrying a gallon of water in each leg.
19.  AFO pearls-- single piece (no articulation) is good for flail or dead foot.  Hinged or articulated brace are preferred more like normal movement only works if patient has some control.  FES is taking over for many. (Bioness or walkaid)
20.  Walkers-- use all wheel or all rolling walkers not ones with "skis" likes U step walker because it has adjustable tension on wheel so patient cannot festinate and has laser light can pattern gait cycle
21.  Pelvic obiquity hurts-- hip, gluteal girdle, takes energy, puts pressure on stance leg, AFO cures, also cures knee hyperextension.  If single piece need to tell orthotist how many degrees of  dorsiflexion (easier with articulated brace) start 5-7 degrees dorsiflexion with single piece
22.  Some people with ballet foot needs to start with botox before AFO for it to work
23.  Do 6 minute walk as well as 25 foot walk to test
24.  Bone loss in men and women--at demarcation of EDSS of 4 and beyond.  Get dexa scans every few years check femur hip and spine
25.  Vitamin D goal is 60-80 not lower level
26.  Dysautonomia in limbs (pain, cold, purple, edema) responds to ciolostazol (pletal) 50 bid or 100 bid affects platelets and relaxes smooth muscle.  May work in Asa resistant strokes too.  Viagra may also work for this, help acrocyanosis
27.  baclofen less sedating than tizanidine,need to monitor lft's.  Zanaflex is less sedating than tizanidine.  May use at night.
28.  hypertensive crisis may occur if stop tizanidine suddenly its an alpha two agonist big rebound effect
29.  Dantrolene last choice can be hepatotoxic need to check, different mechanism, not gaba B or alpha 2 but works on sarcoplasmic reticulum it works sometimes.
30.  Benzodiazepines are drug of choice for phasic spasticity usually clonazepam, some valium, and others GBN, levitiracetam
31.  Botox for focal spasticity especially tight heel cords before bracing
32.  Intrathecal baclofen can be dramatic-- use in patients you  really know well and can trust to do adjustments for nine months realistic expectations are key.
33.  Constipation--pay attention to fluid intake, physical activity, pelvic spasticity (benefit from antispasticity drugs or enemas), drugs  that constipate, bulking agents, softeners, mild osmotics esp magnesium, avoid harsh laxatives, dulcolax or glycerin suppositories.  Enemese plus has both glycerol, docusate (softening) and benzicaine for pain.
34.  Bladder dysfunction ubiquitous even in pediatrics 100 %. Bladder stores to do need 2 things need.  To store need competent sphincter annd relaxed detrusor, and to void need reflexive detrusor and ability to relax sphhincter.  Detrusor hyperreflexia with closed sphincter is commonest type of neurogenic bladder. Symptoms are frequency, urgency, urge leaking, and nocturia.   Dyssynergia of detrusor 2 types.  Both DSD have tight sphincter.  One has detrusor hyperreflexia, urgency, frequency and nocturia, other detrusor areflexia.  This occurs with longstanding disease and leads to high post void residuals.Take history and get a post void residual and if its high send to urologist.If PVR is less than 100 treat, if its greater > 150 send to urologist.  Couuld try relaxation, double void, triple void, vibrator, drugs like Cardura BEFORE intermittent catheterisation.  Patch has 70 % reduction of side effects.  Gel nique new rub on form of oxybutynin. Imipramine for enuresis.  Alpha one agonism ( helps tighten sphincter). If can't get urine out use alpha blocker, such as flomax.  These are sphincter drugs not bladder drugs.  DDAVP most effective drug for nocturia.  Only .1 to .4 at night to reduce urine and decrease voiding.  Don't use in daytime.  If have headache and confused, check sodium (hyponatremia).  Catheters hurt urethra.  Chronic-- consider suprapubic.  Bricker procedure or ileoostomy effective.  (diversion procedures)
35.  intimacyinstitute.com and tootimid.com are 2 online sites to discuss sex
36. Eros clitoral device helps sensation, lubrication, threshold to orgasm its 400 dollars or so. Eroscillator is wall powered three speeds. Wall powered is better need high intensity to get thresholds.  Libigel is hormone therapy for women not yet approved.

differential diagnosis of longitudinally extensive spinal cord lesions

sarcoid
neuromyelitis optica
lupus
Sjogren's
multiple sclerosis
glioma (don't biopsy these patients deteriorate over weeks to months not days)

Pearls

evaluation includes

CSF
ESR
HIV status
CXR
MRI with contrast
B12
copper
Gallium scan for sarcoid
? Ace level
noncontrast CT chest to screen for  neurosarcoid (even in whites)

differential diagnosis of ring enhancing lesions on MRI

h/t Benjamin Greenberg AAN 2010

metastasis
abscess
glioma
lymphoma
infarction
contusion
demyelination
resolving hematoma
radiation necrosis

MS 12 item walking score

• These questions ask about limitations to your walking due to MS during the past 2 weeks.




• For each statement, please circle the one number that best describes your degree of limitation.



• Please answer all questions even if some seem rather similar to others, or seem irrelevant to you.



• If you cannot walk at all, please tick this box.









In the past two weeks, how much has your MS ... Not at all

--------------------------------------------------------------------------------

A little

--------------------------------------------------------------------------------

Moderately

--------------------------------------------------------------------------------

Quite a bit

--------------------------------------------------------------------------------

Extremely

--------------------------------------------------------------------------------



1. Limited your ability to walk? 1 2 3 4 5

2. Limited your ability to run? 1 2 3 4 5

3. Limited your ability to climb up and down stairs? 1 2 3 4 5

4. Made standing when doing things more difficult? 1 2 3 4 5

5. Limited your balance when standing or walking? 1 2 3 4 5

6. Limited how far you are able to walk? 1 2 3 4 5

7. Increased the effort needed for you to walk? 1 2 3 4 5

8. Made it necessary for you to use support when walking indoors (e.g., holding on to furniture, using a stick, etc.)? 1 2 3 4 5

9. Made it necessary for you to use support when walking outdoors (e.g., using a stick, a frame, etc.)? 1

--------------------------------------------------------------------------------

2 3 4 5

10. Slowed down your walking? 1 2 3 4 5

11. Affected how smoothly you walk? 1 2 3 4 5

12. Made you concentrate on your walking? 1 2 3 4 5



--------------------------------------------------------------------------------



Please check that you have circled ONE number for EACH question

© 2000 Neurological Outcome Measures Unit.

Infliximab and central and peripheral demyelination

Neurology AAN 2010 S47:002.  NozakiN, Judson M. Charleston.  2 cases of suspected sarcoid that became worse (central or peripheral demyeination) due to infliximab,  The case of peripheral demyelination improved with plasma exchanges. 

Radiological isolated syndrome

NEUROLOGY 2009;72:800-805

criteria above

44 patients

mean time for those converting to CDMS was 5.4 years

30 percent converted to CDMS, the majority 8/11 with CSF positive bands. The band positive group also had 10/11 with radiographic progression

the biggest risk factor is gad positive MRI lesions

depression scales other scales for PD, AD and MS

http://www.mhsfopcls.com/downloads/ger_dep_scl.pdf Geriatric Depression scale

 

 

http://www.ibogaine.desk.nl/graphics/3639b1c_23.pdf  Beck Depression inventory- pref in Parkinson's disease

 

http://healthnet.umassmed.edu/mhealth/ZungSelfRatedDepressionScale.pdf  Zung SRDS

 

Other scales

http://www.nysaaaa.org/Caregiver_Forum/CaregiverForumErieHandout09.pdf caregiver burden assessment

 

http://www.nationalmssociety.org/for-professionals/researchers/clinical-study-measures/mfis/index.aspx

MFIS with link to MSQLI (Connie is this different than MSQOL and how?)

 

http://www.nationalmssociety.org/for-professionals/researchers/clinical-study-measures/index.aspx

link to links to many clinical tools in MS research

 

http://www.mdvu.org/library/ratingscales/pd/updrs.pdf  updrs and scwab (parkinson;s)

 

http://www.alegent.com/documents/Sleep_eval.pdf berlin and epworth sleep questionnaire

 

http://www.hospitalmedicine.org/geriresource/toolbox/pdfs/clock_drawing_test.pdf clock drawing and mini cog (= 3 word recall)

 

http://www.hospitalmedicine.org/geriresource/toolbox/pdfs/instrumental_activities.pdf Instrumental activities of daily livving (IADL)

http://www.hospitalmedicine.org/geriresource/toolbox/pdfs/phys_selfmain.pdf physical self maintenance scale

 

http://www.hospitalmedicine.org/geriresource/toolbox/pdfs/function_status_questionnai.pdf (last page is functional activities questionnaire)

 

http://www.hospitalmedicine.org/geriresource/toolbox/pdfs/painscales.pdf pain scale

 

http://www.mocatest.org/  Moca-- has links for multiple languages

 

http://www.neurotransmitter.net/alzheimerscales.html   link to MANY Alz assessment tools, behavior and otherwise a few linked below

 

http://strokecenter.org/trials/scales/blessed_dementia.html blessed dementia scale

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MSQOL link

http://www.nationalmssociety.org/for-professionals/researchers/clinical-study-measures/msqol-54/download.aspx?id=261

More studies of cognitive dysfunction in MS

Prakash RS, Snook EM, Lewis JM, Motl RW, Kramer AF. Cognitive impairments in relapsing-remitting multiple sclerosis: a meta-analysis. Multiple Sclerosis 2008; 00: 1-12.

Used 57 studies with 3891 participants with 755 "effect sizes"
Cognitive deficits are reported in broad domains of memory, attention, executive function, and verbal fluency. One report suggested by subtype that PPMS had more problem with executive control, whereas RRMS had more significant memory related dysfunction.

"With exception of motor functioning and mood status, most effect sizes were in the moderate range" MS patients had more trouble with nonverbal than verbal intellectual deficits.
Attention-- most abnormal was selective / focused attention with SDMT, TMT, Stroop word and color reading more than measures of working memory and short term storage. Categories also included processing speed (abnormal), sustained attention/vigilance, executive control, short term storage capacity.

Memory and learning-- categories
verbal immediate recall
verbal delayed recall* key item that was abnormal among subcategories
verbal recognition-- not enough data, item eventually dropped.
visual immediate recall
visual delayed recall, visual recognition

All other categories were medium

Verbal function- normal
categories-- verbal fluency were more impaired than comprehension, verbal expression and discourse.
Other factors-- age > 40 was very important, females more than males. Education, disease duration, and EDSS not important EXCEPT for memory and learning

Motor tests
grooved pegboard, finger tapping, nine hole peg test

Paper 2: Chiaravalottti ND, DeLuca J. Cognitive impairment in multiple sclerosis. Lancet Neurol 2008; 7: 1139-51. review paper. Emphasizes processing speed, attention, executive function and long term memory. Refers to minimal assessment battery (see Benedict RH, Cookfair D , Gavett, R et al. Validity of the minimal assessment of cognitive function in MS. J Int Neuropsychol Soc 2006; 12:549-558. Also refers to re internet based testing, Younes M, Hill J Quinles J, Kilfuss M et al. Internet based cognitive testing in multiple sclerosis. Multiple Sclerosis 2007; 13: 1011-19.
Adds assessment of rudimentary oral motor function, since most tests are done orally.See Arnett et al. JINS 2008; 14: 454-462.

Objective, structured, standardised assessment of functional activity, designed by OT, resulted in executive functions performance test (Baum et al., Cognitive performance in senile dementia of the Alzheimer's type: the kitchen task assessment. Am J Occ Ther 1993; 47; 431-436) found correlation to cognition (Kalmar et al. Neuropsychology 2008; 22: 442-449) whereas subjective assessment of cognitive function correlates with emotional distress. Functional deficits are common including housework, driving, cooking, using public transportation.

Beatty et al. found five variables correlate with 49 % of variance in employment status in MS , 3 of which are cognitive (J Neurol Rehab 1995; 9: 167-173). Benedict found poor cognitiion especially on processing efficiency, verbal memory and executive function predicted vocational status (op cit).

Neuropscch screening test key: Benedict RH , Zivadinov R. Reliability and validty of neuropsychological screening and assessment strategies in MS J Neurol 2007; May 254: s 2 1122-1125.
Amato MP et al. The Rao's BRB and Stroop Test ; nornative values with age, education and gender corrections in an Italian population. Mult Scler. Dec 2006 12: 787-793.
Parmenter BA. Screening for cognitive impairment in multiple sclerosis using the Symbol Digit Modalities Test. Mult Scler Jan 2007 13: 52-57.


Components of BRB-- SRT
10/36 spatial recall test
SDMT
PASAT
Word list generation (20 minutes)

MACFIMS-- takes 90 minutes
COWAS
JLO
CVLT 2d edition
Brief visuospatial memory test
SDMT
PASAT
Delis-Kaplan executive function system scoring test

MS Cognitive Impairment

Possible Panel for Study

MSQOL
Beck or Hamilton Depression Scale
Fatigue Impact Scale
Cognition
Med list
Sexual dysfunction

Test Batteries
*Rao's BRB Brief Repeatable Battery (Neurology 1991; 41:685-691)
Above plus Stroop Color Word Test
MS Neuropsychological Screening Questionnaire
Minimal Assessment of cognitive function in MS

Individual tests
PASAT
Symbol Digit Modalities Test (adapted for use in MS)
California Verbal Learning Test
Brief Visuospatial Memory Test (revised)
Delis-Kaplan Executive Function Symptom, Sorting Test
Controlled Oral Word Association Test
Judgment of Line Orientation Test
Auditory Consonant Trigrams
WCST
Trails A/B
WMS Revised
Rey COmplex Figure
EDSS


Published studies
Aricept Christodoulou et al. CNS Drugs 2008; 22:87-97 and J Neurol Sci 2006; 245: 127-136.
Avonex-- benefit after two years see Fischer et al. Ann Neurol 2000; 48:885-892.
Betaseron-- small group study Barak et al. Eur Neurol 2002
Copaxone-- open label ext trial (Schwid et al. J Neurol Sci 2007) suggestive of benefit
COGIMUS (Cog in MS) Italian study prospective Italian study with cognition measured annually using BRB and Stroop

Post optic neuritis (Nilsson P, Rorsman I, Larrson EM, Norving B, Sandberg-Wollheim M. Cognitive dysfunction 24-31 years after isolated optic neuritis. Multiple Sclerosis 2008; 14:913-918. was case ascertainment study of 110 individuals, 86 of whom consented to followup 22 who did not have MS and who were alive underwent further testing. Most common abnormalities were WCST (exec function) and Trails A (attention) and Rey Figure. Less affected, BNT, verbal learning, verbal memory or verbal comprehension (Token Test). There was not much correlation with MRI findings.

Sources for MS Cognitive Screens

Computerized testing
Wilken JA, Kane R, Sullivan CL et al. The utility of computerized neuropsychological assessment in patients with relapsing-remitting multiple sclerosis. Mult Scler. 2003;9:119-127.

brief screening
Parmenter BA, Weinstock-Guttman B, Garg N, Munschauer F, Benedict RHB. Screening for cognitive impairment in MS using the Symbol Digit Modalities Test. Mult Scler 2007; 13:52-57.

also see
Benedict RHB, Cox D, Thompson LL, Foley FW, Weinstock-Guttman B, Munschauer F . Reliable screening for neuropsychological impairment in MS. Mult Scler 2004; 10: 675-678.

Suggest use of above with concurrent measures for depression and fatigue for minimal cost.

Once cognitive impairment is identified, can then use other measures to follow it These include The Brief Repeatable Neuropsychological Battery for MS (BRNB) see Rao SM. A Manual for the BRNB in MS. New York, National MS Society, 1991.

Or, The Minimal Assessment of Cognitive Function in MS (MACFIMS). JINS 200612: 549-558.

Former has more non English assessments

Purpose to detect worsening MS or non benign MS.

Possible Journal Club article: Portaccio E. et al. Neuropsychological and MRI measures predict short term evolution in benign MS. Neurology 2009; 73:498-503.

PML A Stochastic event before brain infection

per Dr Joe Berger's talk at AAN. A number of necessary events must occur

1. 80 % of individuals are infected with JC virus, virtually all by age 20.

2. Latent primary viral infection must occur, involving spleen, kidney, bone marrow, tonsil, oropharyngeal lymph nodes and other tissues. Controversial whether it is latent in brain. Virus appears incapable of replicating in brain. Must have receptor to allow virus to bind.

3. Infected cell must have NF 1X to allow virus to replicate

4. 98 base pair tandem repeat within nucleus probably within B cells must allow insertion to allow replication of virus within brain (b cells must activate)

5. Failure of immunosuppression in periphery and allow detectable JC virus in blood (see IgG antibody in blood suggesting its reactivated infection)

6. Periodic reexpression of JC virus in PBMC

7. Entry of JC virus into brain and allowance of productive oligodendrocyte function

8. Failure of immunoregulatory function in the brain

Natalizumab-- may cause release of B cells and ciruculate, premature and mature B cells and increased transcription factors resulting in a productive infection. Decreased immunosurveillance in brain. JC toxic circulating t lymphocytes are important. Also loss dendritic cells responsible for antigen presentation.

Rebif site reaction

Memantine transiently worsens MS

Villoslada P et al. Memantine induces reversible neurologic impairment in patients with MS.
30 patients underwent a one year randomized crossover trial with 30 mg memantine. Patients had poor cognitive scores and MS . The trial was halted after 9 patients due to blurred vision, fatigue, headache, increased muscle weakness, trouble walking/gait. Symptoms only occurred at maximum dose.

Early MRI in ON" Risk for disability

Swanton et al. Neurology 2009; 72: 542-550. (Queen's Square)
106/143 patients reached scheduled five year followup after being diagnosed with ON. 100 were evaluated clinically. At median 6 years, 48 % converted to CDMS 52 % did not. At baseline, the presence and number of spinal cord lesions and new T2 lesions at followup (odds ratio, respectively of 3.3, 1.94, 7.12) predicted higher disability. Also Gd+ lesions and number of infratentotial lesions at baseline were predictive.

Many factors were not predictive including age, gender, baseline EDSS, spectros/MTR measures, NOT baseline lesion number although lesion load at 5 years and increase from baseline was predictive.

ACT trial negative

Cohen et al. Neurology 2009: 72:535-541.

There were 313 subjects, no benefit of adding IVMP or MTX to interferon beta one alpha. Trend to less NABs. It was safe and well tolerated. There was a trend to benefit in the IVMP group.

ECTRIMS 2007 Therapy papers

QD v QOD GA suggests possible role of qod therapy. Khan plans 3 arm study multicenter randomized of daily v qod v weekly.

Perfumal et al. Uses IIS (intense immunosuppression) as inital therapy in active rrms patients. In active patients used 6 months of monthly cytoxan before beginning DMT first line, with good results on clinical and MRI outcomes.

Mancuso et al. JC virus has 9.8 % prevalence in CSF,mostly asymptomatic.

Imaging studies at ECTRIMS 2007

Calabrese et al. Used double inversion recovery (DIR) sequences to assess cortical lesions over 24 months in rrms, found more cortical lesions in untreated patients.

Haacke et al. SWI (susceptibility weighted imaging) to detect/quantify tissue iron; on 1.5 T machine, 78/141 lesions were seen on SWI only in gray and white matter; on 3 T machine, 20 lesions were seen on SWI only (our of 90 lesions); on 4 T machine 45/116 lesions were seen on SWI only. Iron content found 47 ug.gm higher than normal.

Kahn O. et al. B Cell response (CSF IgG index) correlates with gray matter atrophy in clinically aggressive disease.

Complications after 5 years of DMT in MS

Caon C. et al
Copaxone-- 89 % had local injection site reactions and 78 % had lipoatrophy. No other complications were significant.

SQ IFN B- 38 % flu like reactions, 68 % local injection site reactions, 11 % injection site necrosis, 41 % lipoatrophy, 8 % abnl LFT and 8 % abnl CBC, 25 % headache

IM IFN B-- 22 % flu like 18 % local injection site reaction, 24 % severe post injection reaction, 6 % abnl LFt, 9 % headache.

Injection compliance five years into continuous therapy:
taking 90% or more scheduled injections per month: SC IFn >70, im IFN 58, GA 20 %
taking 70-90 % of scheduled injections per month: all 3 around 20 %
taking <70% of injections: GA around 60, IM IFN about 25, SQ IFN <10 %

Hits Ectrims 2007 HHV6, Vit D, Rebound

Marmocets who were injected with HHV6 got subpial inflammation and parenchymal demyelination, those who did not get injected did not get it. The suggested causal mechanism is CNS persistence of HHV6A and direct toxicity to cells, with resultant apoptosis.

_Genain CP et al.
Blogger note-- HHV6 is so ubiquitous in humans its impossible to study, as almost 95 % prevalence exists in human population

Vitamin D-Correale et al. In vitro, Vitamin D effects are very similar to interferons. 1,25 Vit D inhibits proliferation of CD4+ cells, enhances IL 10, decreases IL 6, increases number of CD4 and CD 25 regulatory cells.
Blogger notes-- amounts being studied in clinical trials are manifold higher than the amount available and are potentially extremely toxic. Also, vitamin d levels are of little use.

Stopping DMT: No rebound Bejaoui et al. Stopping ifn or GA did not result in more relapses than continuing therapy. Blogger notes--only one year followup was offered with no MRI evidence. What happens in year 2?

Campath for multiple sclerosis

Alemtuzumab vs. interferon Beta-1a in early multiple sclerosis. The CAMMS223Trial Investigators. NEJM 2008;359: 1786-1801. (phase 2 trial)

In patients with early RRMS alemtuzumab (Campath 1H) was more effective than interferon-1a but was associated with autoimmunity most seriusly manifesting as immune thrombocytopenic purpura. The study was not powered to detect uncommon adverse effects.

Blogger notes. The investigators deserve credit for going up against Rebif (high bar to hurdle) and then hurdling it. Autoimmune events included in addition to ITP, Graves' disease and Goodpasture's syndrome. The patients studied all had MILD MS (EDSS was less than or equal to 3) in naive patients and no conclusions can be drawn about its use in advancing patients or as switch therapy in patients who have had the disease more than three years. The conundrum in a brand new patient is whether to use the most effective drug when it works (Campath) before they fail Rebif, even though it exposes the patient to the risk of autoimmune disease on Campath, because Campath might not work if given later (see 1999 paper on Campath in 2pms). In addition, it is not clear how many times to dose Campath. In this study, subjects were dosed one, two or three times, with eight protocol changes during the study. One or two times should be enough, but Genzyme wants to try to test using the drug every year. A final issue is the use of concomitant drugs-- once campath is finished. Should none be used (the allure), or copaxone ? Does the risk of adverse effects increase with each dosing? We need more answers before Campath can be widely utilized.

BECOME trial

Betaseron v. Copaxone with triple dose gado and 3T MRI. Head to head trial with combined active lesions as primary endpoint. No difference between 2 groups in 75 randomized patients. In a secondary endpoint, IFN but not GA has a drop in active lesions from pre treatment. Not clear what this means

Combination therapy mitixantrone + copaxone

Journal of Neurology 253 November 2006 Mike Boggild Liverpool Induces the MTX then gives GA. Uses for severe or active disease. Uses MTX 20 mg for 3 months then 2 quarterly doses of 10 mg for total of 80 mg. In fifth month GA is initiated. Data on 60 patients is presented . All patients were in first 3 years since onset. Relapses went from 2/year to none. Suggested synergy.

Khan's five year imaging data

Background--
Rudick showed brain parenchymal fraction declines in MS
Summers showed cognitive impairment is proportional to atrophy (MS 2008)
Khan looked at 5 years of patients treated continuously with one drug (n=608) picked (how?) 275 including 121 GA 101 high dose IFN 57 low dose IFN used SIENA technique updated in 2004 to include voxel based analysis reliable to 5 mm gaps. He threw out the first year due to known problems with "pseudoatrophy" which is due to loss of extracellular fluid. Was interested in changed in atrophy from year 2-5.
.
Note that in BEYOND beta 500 , beta 250, and GA had the following amount of atrophy at year one and two: -.9(second year). I Khan study at 2 years IFN -.64, GA was -.46. In interval to year five, betaseron had -2.2, Avonex had -1.83, and GA had -1.4, controls -3.8.

Predictors of disability in MS

Robust--
Incomplete recovery after first attack
short interval to a second attack
sphincter affected at onset
motor function affected at onset

Others-
increased age
male gender
multifocal onset with cerebellar involvement

PRECISE Comi et al. for CIS using copaxone

481 patients 81 centers 1:1 randomization 3 years then openlabel extension. For entry patients had to have a unifooal attack and more than 2 large MRI lesions and enroll within 90 days . There was a robust effect on MRI and black holes, data on EDSS is pending. There was a 45 % reduction in relapse rate.

Current clinical trials/ recent trials quick hits August 2008

PRECISE Comit et al CIS and copaxone 481 patients 81 centers 1:1 randomization 3 years then open label robust effect on conversion to CDMS, black holes, EDSS data is pending.

 

FORTE study-- dosage study of copaxone 20 v. 40 mg 1155 patients 12 months negative  result

 

CHAMPS   (older study ) best prediictor of relapse is Gd++ lesions

 

BEYOND-- Betaseron 25v. Betaseron50 v. copaxone-- year two brain atrophy data was -.63, -.64 and -.59 respectively, favoring copaxone

 

REGARD  year two atrophy -.6% for rebif,-.5 % for copaxone favors copaxone but beware of pseudoatrophy effect in year one

 

CAREMS1 phase 3 Campath trial for naive early active patients

 

CAREMS2 phase 3 Campath trial for treatment failures on IFN who relapse with rrms 1200 patients

 

Freedoms  fingolimid, 2 doses .5 and 1.25 v placebo

 

Tranforms fingolimid v avonex

 

DEFINE BG12 fumarate dose finding 240 bid v tid

 

CONFIRM  fumarate v. comparator (which one?)

 

CLARITY  cladribine phase 3 pivotal fast track

 

ORACLE  cladribine trial for CIS

 

BRAVO  laquinomodv. placebo for rrms

 

OlympusRituxan v.placebo for PPMS failed trial in press

 

HERMES    Rituxan v. placebo for rrms reported in NEJM 2008

 

CAMMS223 Campath for RRMS phase 2 trial in press NEJM

 

 

 

 

 

 

 

 

 

 

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Infratentorial lesions predict disability in MS

Minneboo A, Barkhod F, Polman CH et al. Infratentorial lesions predict long term disability in patients with initial findings suggestive of multiple sclerosis. Arch Neurol 2004; 61:217-221.

42 patients assessed over 8.7 years. Thos chosen had initial findings c/w MS based on MRI and these patients were followed until they achieved EDSS of 3.0. 26/42 converted to CDMS (clinically definite MS). Gad lesions and hypointense T1 lesions were not predictuive. 2 or more infratentorial lesions best predicted disability.

Sastre-Garriga J, Tintore M, Rovira A et al. Specificity of Barkhod criteria in predicting conversion to multiple sclerosis when applied to clnically isolated brainstem syndromes.
Arch Neurol 2004; 61: 222-224.

51 patients with CISB (clinically isolated brainstem syndromes) and 102 with other CIS (clinically isolated syndromes) were followed for 34, and 40 months respectively. (The CIS had 46 with transverse myelitis and 56 with optic neuritis). The specificity of the Barkhof criteria was less in CISB v other CIS (61 v 73 %), due to infratentoria lesion requirement having less specificity (no dissemination in space). Conclusion-- beware of specificity in CISB

Fatigue in MS

Factors causing/correlating with fatigue in MS
1.Depression
2. Deconditioning
3. hypothyroidism
4. anemia
5. medications
6. ambient temperature
7. relapse/exacerbation
8. psychological concerns
9. N acetylaspartate-creatine ratio in MR spectroscopy (indicates axonal damage)

NOT correlated
1. T2 lesion volume on MRI
2. Gad lesions
3. C reactive protein
4. transcranial magnetic stimulation response (measure of motor conduction) not difference in larger fibers (may not be the ones involved in fatugue)

Source-- editorial Arch Neurol 2004Feb pp.176-177 Michael Racke Kathleen Hawker and Eliot Frohman, Fatigue in multiple Sclerosis: is the picture getting simpler or more complex

The contribution of demyelination to axonal loss in multiple sclerosis

DeLuca GC. Brain 2006; 129: 1507-1516. An autopsy study of 55 patients with MS prior to death age range 25-83 noted no or a weak correlation between MS plaque load and axonal loss. Both were studied and evaluated microscopically. Spinal cord plaque load was also not closely related. The study indicates the need to reconsider the inflammatory hypothesis as the sole basis with which to assess the efficacy of MS treatments, particularly in certain patients.

HERMES trial for relapsing multiple sclerosis NEJM article

Hauser S SL, Waubant W. Arnold DL, Vollmer T, et al for HERMES Trial Group. B Cell Depletion with rituximab in relapsing remitting multiple sclerosis. NEJM 2008; 358: 676-678

and editorial
McFarland HF. Focus on research: the B Cell -- old player, new position on the team. NEJM 2008; 358: 664-666.

The phase 2 trial of Rituxan (Rituximab, Biogen Idex and Genentech) in relapsing remitting multiple sclerosis showed a significant reduction of relapses and of MRI lesions, the primary outcome measure. It was a short trial (48 weeks) and not powered to show an effect on disability. There was a rapid reduction not only of contrast enhancing lesions on MRI but also total lesions, within 4 weeks. McFarland opines that the benefits of led to increased interest in the role of B cells in diseases thought to be mediated by T cells. Some patients may have antibody mediated complement destructive lesions and in others B cells may precede lesion development. However the rapidity of the response suggests another mechanism. Possibly, B cells are involved in antigen presentation to T cells and activation of T cell programming (cites Rock, 1984). They may contribute to T cell priming and lesion formation. Treated patients showed the subsequent development of naive rather than memory B cells.

Many trials have shown a reduction of MRI lesions but not clinical disease activity. Since antibodies maybe involved in repair mechanisms, clinical status of the patients will need to be closely monitored in the phase 3 trial. B cells may alos be important within lesions, as CXCL13 which regulated B cell migration in lymphoid tissue is found within plaques.

The study is a phase 2 trial, which means that unanswered questions include low frequency side effects, duration of oeffect, and effect on disability. The study involves only 104 patients.

Side effects of interferon beta

1. cutaneous reaction
2. hyperthyroidism (Schwid et al. Arch Neurol 1997;54:1165-1190)
3. transvaginal bleeding (Pakulski et al., 1997 Ann Pharmacother311:50-52)/
4. liver carcinoma (Makita et al., Nippon Shokakdyo, Sasshi 1996;93:406-410)
5. psoriasis (Webster et al., J Am Acad Derm 1996; 34:365-367).
6. transitory hearing loss (Kanda et al., Audiology 1995; 34: 98-102)
7. polymyositis
8. intraocular bleeding
9. Severe anaphylaxis-- sudden laryngospasm and shock after taking drug for six months
10. flulike illness, fatigue and headache
11. depression

Consensus statement on CSF standards in diagnosis of MS

Freedman MS, Thompson EJ, Deisenhammer F, et al. Recommended standard of cerebrospinal fluid analysis in the diagnosis of multiple sclerosis. A Consensus statement. Arch Neurol 2005; 62:865-870.

general points
1. The IgG index or any other quantitative IgG anaysis is not equivalent to qualitative analysis using isoelectric focusing with immunofixation, as opposed to the previous recommendation that equated the IgG index with qualitative analysis.

There is complete agreement that isoelectric focusing (IEF) on agarose gels followed by immunoblotting should be the gold standard for detecting oligoclonal bands. Other methods such as polyacrylamide gels combined with IEF and silver staining of proteins might have proved useful IN THE PAST but they LACK SPECIFICITY for IgG and are not supported by consensus. Direct silver staining techniques demonstrate reduced sensitivity and specificity.

Some techniques also stain kappa and gamma light chains (both free and bound) that discern faint bands better against polyclonal background. Light chain staining will also be positive in rare cases where OCB's are caused by the presence of IgA or IgM which will not appear on gels stained only for IgG. These add little to routine MS diagnosis.

Serum free chains are usually removed by kidney (free chains). Intrathecal IgG is usuallyy associated with kappa chains.

Sensitivity of using IEF with immunoblotting is in excess of 95 %. A negative test is an indication to rethink the diagnosis. The presence of only one band in CSF not in serum may indicate the need to retest as many patients will convert. There is a high negative predictive power of negative CSF in clinically isolated syndrome (CIS) such that a negative CSF exam indicates a low likelihood of developing MS. There are five patterns accepted (1- no bands in CSF or serum 2- OCB in CSF not in serum 3-- OCBs in CSF, identical bands in serum (still there is CSF IgG synthesis) 4-- same as 3 except with leaky BBB suggesting systemic oligoclonal band production 5-- Monoclonal bands in CSF and sera, suggestive of a monoclonal IgG protein present).

Q albumen (albumen quotient) can be used to assess CSF leakiness. Controls should be run with each sample to make sure that OCB's in positive controls are not overdeveloped and negative controls are not underdeveloped.

Patients deserve to have CSF analyzed at a lab that utilizes accepted standards.

Hematopoeitic stem cell transplantation for multiple sclerosis

Burt RK, Cohen B, Rose J et al. Arch Neurol 2005; 62: 860-864 Neurologic Review.

Authors comment intial attempts by hem-onc specialists used hem-onc protocols targeting SPMS patients. Recent trials from MS specialists with earlier patients are encouraging with less morbidity and mortality and improvement in EDSS. The key factors in success are selecting active patients (active by MRI or clinical criteria), treatment early before progressive disability ensues, and use of safer lymphoablative but not myeloablative HSCT conditioning regimen.

Rationale-- transplant ablates the aberrant disease causing immine cells while transplanted cells regenerate a new and antigen naive immune system.

Animal models -- Theiler murine encephalomyelitis virus (TMEV) in mice is a persistent viral related autoimmune disease, wherease EAE is a relapsing disease like MS. HSCT should be done while still in immune mediated inflammatory process not chronic progressive process.

Mobilizing hematopoietic stem cells (HSC's) from patients with MS-- HSCs are mobilized from peripheral blood from bone marrow with a growth factor such as granulocyte colony stimulating factor or chemotherapy (cyclophosphamide). GCF's can induce worsening of MS sometimes irreversibly and thus are prevented by administering steroids or cyclophosphamide. Ex vivo, lymphoctes and monocytes are purged and stem cells are selected, sometimes with monoclonal antibodies.

Conditioning regimen-- again the goal is lymphoablation not myeloablation. Myeloablative agents anyways will kill stem cells. Total body iradiation has the potential of causing neural stem cell apoptosis. Non myeloablative regiments include fludaribine, cyclophosphamide, Campath 1h, antithymocyte globulin. Fever induced pseudoexacerbations due to conduction blocks in marginally functional demyelinated axons should be avoided. The goals are 1) dose escale agents that work as conventional therapy 2) maximize immune suppression without myeloablation 3) avoid conditioning agents that injure disease affected and damaged CNS tissue 4) minimize the risk of fever 6) design justifiable regimens.

First generation protocols-- were extremely effective on MRI but not clinically due to late stage patients selected. tHERE WERE ALSO TREATMENT RELATED DEATHS.

Second generation therapies: the rationale for autologous HSCT is that MS is an environmentally caused disease, not a genetic stem cell defect. Nonmyeloablative treatments would presume to be more safe, following which HSC are infused to shorten period of cytopenias. Ruled OUT are etoposide, total body irradiation, busulfan, melphalan, and carmustine. Instead, cyclophosphamide and Campath 1H are used. Criteria are active disease despite treatment and EDSS 2.5-6.0, or higher if they have rapid deterioration and activity on MRI. A German protocol uses cyclophosphamide and rabbit antithymocyte globulin. At Northwestern, a regimen of cyclophosphamide and Campath 1H is used. More than half do not requrie a blood transfusion.

Comment-- to my knowledge this therapy is cash on the barrelhead, which has given some serious MS researchers pause in suggesting it.

MRI as a surrogate measure for disease activity in MS

See Neurology suppl. 3 2002 p. S29
Authors note that in the main clinical trials the correlations between relapse rate and EDSS progression with T2 burden are generallyin the range of 0.15 to 0.30. MRI cannot be used to predict EDSS progression or relapse rate. Autors cite the "Prentice criteria" a statistical look at what makes a surrogate marker. (Prentice R. Surrogate markers in clinicl trials: definition and operational criteria. Stat Med 1989; 8:431-440) states the surrogate marker must closely mirror the gold standard which here, is clinical activity.

Rating the main MS studies (the classics)

from Neurology suppl 59;S3 2002
CHAMPS Avonex v. Solumedrol/placebo Outcome point CDMS NOT disability, relapse, brain atrophy. NTT 6.7 to prevent one conversion to CDMS over 3 years. Class I Category A trial

Beta1a v. placebo. Primary endpoint was confimred EDSS progression between treatment group and controls. Relpase rate was a secondary endpoint. EDSS 1-3.5 at entry, 2 relapses in 3 years. Only 57 % of patients completed 2 years. Proportion with a one point increase in EDSS was 21.9 v. 34.9 % in treated/control groups, respectively. (p=0.02). Relapse rate improved by 18 %. Among the subgroup that completed 2 years of treatment there was a 31 % reduction of relapses. There was a 50 % reduction of Gad+ lesions but only 165/301 patients were included in this analysis. There wa no effect on T2 burden. NAbs were seen in 22 % by week 104. NTT to prevent one point increase in EDSS was 7.7. Class I Category A. However, it was short study was stopped early , studied a restricted population (mild entry EDSS 1-3.5) and showed decreased disability but no effect on T2 burden .

ETOMS Rebif 22 sq/per week v. placebo . Unlike CHAMPS, no steroids given in placebo group. No change in EDSS seen. MRI showed a benefit. NTT 9.1 to prevent one CDMS in 2 years. Class I Category A trial

PRISMS patients with 2 relapses in 2 years with EDSS 0-5.0 were reandomized to Rebif 22, Rebif 44 or placebo. Active treatment increased the time to progression of disability and reduced the probability of progression, and reduced the median integrated Disabiliyt status Scale score (area under the curve) mean increase in EDSS and mean increase in Ambulation Index. It reduced relapses, reduced moderate and severe relapses, number of steroid courses, and number of hospitalizations. It increased the number of relapse free patients. T2 burden increased by 10 % inplacebo and decreased with both treatment arms. Number of active lesions also was significantly reduced. 90 % completed 2 years and 95 % were followed for two years. NTT (high and low dose Rebif) to prevent one relapse per year, was 2.4, and 2.7, to render one patient relapse free for one year, 4.3 and 6.7; to render one patient relapse free for two years, 6.3 and 9.1; to prevent one moderate to severe relapse over two years, 2.7 and 3.6; and to prevent onepoint progression in EDSS, 9 and 12. Class I Category A. Rebif prevents progression of disability and reduces relapses in MS.

PRISMS 4-- extension of trial to four years. primary endpoint was relapse rate, with main comparison high dose angainst placebo. Original placebo patients were rerandomized to high or low dose. A dose effect relationship for disability was seen in years 3 and 4. Relapse rate was better with treatment but not with high dose treatment. The higher dose was significantly more effective for time to second relapse and the need for steroids. MRI was always better in the earlier treated patients. 20 % + of patients switching from placebo to drug developed NAbs. NTT not calculated. Class I, Category A. The trial established that Rebif 22 or 44 was effective in reducing relapses, delaying disability, improving MRI markers(t2 burden and no of new T2 lesions per scan) but no difference between high and low doses.

Interferon B1b in RRMS EDSS 0-5.5. gave betaseron 1.6 or 8 miu sq qod. Not well blinded, but randomized. No beneficial effect of EDSS found. Significant effect found on time to first relapse, proportion of patients relapse free, relapse rate, , number of moderate or severe relapses, and need for hospitalization over two years. MRI lesion burden increased by 20 % in placebo group, 10.5 % in low dose group, and decreased by 0.1 % in high dose group. NTT was 2.3 patients to prevent one relapse per year in this actively relapsing group. NTT 5.6 patients to keep one patient relapse free for two years, and 4.5 to prevent one moderate or severe relapse in one year. Class I category A

Extension study of Beta ib. Primary outcome measures were time to sustained worsening by one point on EDSS and mean change in each group from baseline. Not blinded. Study showed a trend (p=0.096) on time to sustained disability over five years with NO DATA GIVEN on other stated endpoint of mean change in EDSS. Both doses led to better relapse data for whole five year period. Rate of moderate and severe attacks was lower in both groups. Less patients completed years 3-5. MRI was beneficial for treated group although numbers were small at this point of study. There were 154 dropoutsby then en d of the study. NTT not calculated. Class II Category B, shows an effect for relapses only.

Copolymer (glatiramer acetate) GA v. placebo baseline EDSS of 0-5.5 . There was no effect of EDSS. Relapses were reduced 29 % over two years. MRI data not presented. NTT was 2.7 to prevent one relapse over two years. Class I Category A study for relapses.

Open label extension trial. Disability data gleaned against natural history data. Annual relapse rate of 0.42 over both phases of trial was stated as 72 % reduction over 2 years before study entry is misleading as it only was calculated with 83 patients and no account was made for regression to the mean. No MRI data exist. Injection site reactions were reported as 2.4 %. There was 27 % dropout. Class II Category C.

IVIG-- insufficient quality to be evaluated

Mitoxantrone randomized MRI blinded patients with aggressive MS EDSS <> 1.0. Entry 2 relapses in 2 years. EDSS outcome was better in treatment group (7 % progresses v. 37 % changed by one point over two years; however there was no change in MEAN change in EDSS score. Relapse outcome over 2 years was .89 v. 2.62. Percent relapse free was 63 v. 21 % all significant. NTT was 3.3. Class II/III Category C study due to trouble blinding.

MIMS MTX in SPMS bseline EDSS 4.5-7 with one point deterioration in year prior to entry. Primary endpoint was a composite of EDSS, Ambulation Index, number of relapses requiring steroids, and Standard Neurologic Status. The result was highly significant p<0.0001). There was a difference in groups on EDSS progression, at 6 months, mean number of treated relapses, time to first treated relapse, percentage of patients without a relapse, totoal number of relapses, and number of hospitalizations. Class II Category B. Key point is that it was ana actively relapsing group in the two years before study entry.

Secondary progressive MS:
Interferon B1b (European) entry 3-6.5 EDSS 70 % of patients had relapses in 2 years before study entry. Progression of disability was 49.7 % v. 38.9 % p=0.0048, also less patients became wheelchair bound. Relapses were reduced by about 30 %. No treatment effects in patients with baseline EDSS 6.0 or 6.5. Decreased T2 burden. NTT was 9.2 patients for 3 years to prevent one point EDSS increase. Class I Category A. Difference with SPECTRIMS (North American study) might be due to less pre treatment relapses in N American group.

Head to Head
INCOMIN Beta 1b v. Beta 1a (Betaseron v. Avonex) 2 year trial, primary endpoint was no of relapse free patients, and number of patients with no new T2 lesions on their MRI. Entry 2 relapses in 2 years, EDSS 1-3.5. EDSS progression of one point was 13 % over 2 years with Betaseron, 30 % with Avonex. T2 lesion burden showed o new lesions in 55 %with Betaseron, 26 % of those with placebo. NTT to make a patient relapse free for 2 years was 7 for betaseron v. avonex. Class I for MRI, Class III for clinical outcomes (unblinded)


EVIDENCE Rebif v. Avonex. primary endpoint was proportion of patients who were relapse free at 24 weeks. entry edss 0-5.5, pastients who got Rebif received 44 mcg tiw dose. Evaluating neurologists were blinded. There was no change in disability. Relapse free patients favored Rebif (74.9 v. 63.3 %, odds ratio 1.9, p=0.0005). Combined unique active lesions on MRI favored Rebif. NTT was 9 at 24 weeks and 10 at 48 weeks. Class I study.