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CMSC: Survey offers snapshot of MS therapy trends
INDIANAPOLIS – Although nearly all patients with multiple sclerosis have some form of insurance, 25% of them receive some form of assistance from the pharmaceutical industry in covering the cost of their disease-modifying therapies. In addition, 22% report that their health insurance coverage worsened compared with the prior year.
Those are key findings from a fall 2014 survey of the North American Research Consortium on MS (NARCOMS), a registry with self-reported information on disease-modifying therapies (DMTs), including type, duration of use, changes and reasons for changes, as well as income, insurance, and disease status.
At the annual meeting of the Consortium of Multiple Sclerosis Centers, Guoqiao Wang, Ph.D., and his associates reported findings based on 6,662 (88%) of 7,601 NARCOMS participants who completed the Fall 2014 NARCOMS Update survey, including questions about their health insurance status and DMT choices related to insurance. Of those 6,662 respondents, 99% reported being insured in the prior 6 months, 69% reported that their insurance coverage was unchanged compared with the prior year, and 22% said that their insurance coverage worsened compared with the prior year.
Of the 4,156 (62.4%) respondents who were taking DMTs at the time of the survey, the following financial resources were used to pay for the agents: health insurance copay only (52.1%), free or discounted drug programs (25%), full coverage by health insurance (22.2%), and full payment by the patient (0.7%). Most of those who received assistance from free or discounted drug programs were female (86%), have had their disease for a mean of 7.6 years, tended to have the relapsing-remitting form of MS (71%), and had a median Patient Determined Disease Step of 3 (Gait Disability), suggesting a lower level of disability and most likely an earlier stage of the disease course.
Of the 2,108 (31.6%) respondents who were not taking DMTs, 77.7% did so by their own choice, 14.5% did so on physician recommendation, 3.8% did so because of insurance denial, 2.7% did so because of a higher copay, and 1.3% because of having no insurance.
“Although the proportion of participants who did not take DMTs due to insurance denial was low, the absolute number of participants was 80, which is relatively high,” Dr. Wang, a research fellow at NARCOMS, said in an interview. “We don’t consider that a small number. The free or discounted drug programs helped a lot of participants obtain DMTs at the relatively early stage of their disease, even those with health insurance. On the other hand, 77.7% of those who were not to taking DMTs had a median Patient Determined Disease Steps of 4, indicating a higher level of disability (using a cane or walking aid) and more likely at a later stage of the disease course. For some of these participants, they may have entered a secondary progressive phase, where there are limited options for DMTs. The contrast between these two groups of participants showed that the free or discounted drug programs not only helped them get access to DMTs, but seemingly also helped them to get DMTs earlier, and thus maximized the benefits of DMTs.”
Of the 398 (6%) respondents who changed their DMT over the 1-year time period studied, nearly half did so for insurance-related reasons, including denial by the insurer (22.4%), higher copay resulting in a decision to skip or split DMTs (12.8%), insurance change (8.3%), and higher copay resulting in a change of DMT (4.3%).
“It’s important for neurologists to know that while their patients are likely to have insurance, a deeper discussion on how they’re going to get their medications covered is warranted,” Stacey Cofield, Ph.D., deputy director of the NARCOMS Coordinating Center, based at the University of Alabama at Birmingham, said in an interview.
In a separate abstract presented at the meeting, Dr. Cofield and her associates reported results from the same Fall 2014 Update survey of 7,601 NARCOMS participants who addressed questions about their DMT status, changes to their DMTs, and how the decision to switch or continue was made. The researchers found that 42.8% of respondents shared decision making with their physicians or spoke with their physicians prior to making a treatment decision (38.8%). They also found that patients currently on a DMT were more likely to engage in shared decision making, compared with those who were not on a DMT (47.4% vs. 33.5%; P < .0001). Patient-centered decision making increased with current worse PDDS (P < .0001).
According to Amber Salter, Ph.D., of NARCOMS, about 3% of MS patients switch DMTs within a 6-month period (Patient Prefer. Adherence 2014:8 971-9), a number that has been increasing in recent years for a variety of reasons. For example, a patient may want to switch from an injectable agent to an oral medication out of perceived convenience, not realizing that being on the oral agent may involve an increased number of office visits for blood testing during treatment, she said.
Difficulty can arise when the patient and the physician both agree on a DMT switch, but the patient’s health insurer says no. “The clinician’s best judgment is, ‘I’ve seen the MRI. There’s activity in the brain. I want to change to a different medication.’ But the insurance company says, ‘You don’t meet our criteria,’ ” said Gary R. Cutter, Ph.D., director of the NARCOMS Coordinating Center. “The patient doesn’t know what to do. The physician can fight [that decision by the insurer], can get involved in that battle. But that’s a different battle that not all physicians have the resources around to tackle. It can be a hassle for both the patient and physician.”
Dr. Cutter noted that MS patients who switch DMTs tend to do worse from a clinical standpoint. “If you look cross-sectionally at data, people who have switched end up with higher levels of disability, and it’s because the physician is reacting to something; it’s not that the drug they switched to is bad,” he said. “These drugs are not cures. They’re meant to slow the progression [of MS].”
NARCOMS is supported by the CMSC and the Foundation of the CMSC. Genentech provided additional support for the survey of treatment decision making. Dr. Cutter disclosed ties to several pharmaceutical companies. The other researchers stated that they had no financial conflicts to disclose.
On Twitter @dougbrunk
INDIANAPOLIS – Although nearly all patients with multiple sclerosis have some form of insurance, 25% of them receive some form of assistance from the pharmaceutical industry in covering the cost of their disease-modifying therapies. In addition, 22% report that their health insurance coverage worsened compared with the prior year.
Those are key findings from a fall 2014 survey of the North American Research Consortium on MS (NARCOMS), a registry with self-reported information on disease-modifying therapies (DMTs), including type, duration of use, changes and reasons for changes, as well as income, insurance, and disease status.
At the annual meeting of the Consortium of Multiple Sclerosis Centers, Guoqiao Wang, Ph.D., and his associates reported findings based on 6,662 (88%) of 7,601 NARCOMS participants who completed the Fall 2014 NARCOMS Update survey, including questions about their health insurance status and DMT choices related to insurance. Of those 6,662 respondents, 99% reported being insured in the prior 6 months, 69% reported that their insurance coverage was unchanged compared with the prior year, and 22% said that their insurance coverage worsened compared with the prior year.
Of the 4,156 (62.4%) respondents who were taking DMTs at the time of the survey, the following financial resources were used to pay for the agents: health insurance copay only (52.1%), free or discounted drug programs (25%), full coverage by health insurance (22.2%), and full payment by the patient (0.7%). Most of those who received assistance from free or discounted drug programs were female (86%), have had their disease for a mean of 7.6 years, tended to have the relapsing-remitting form of MS (71%), and had a median Patient Determined Disease Step of 3 (Gait Disability), suggesting a lower level of disability and most likely an earlier stage of the disease course.
Of the 2,108 (31.6%) respondents who were not taking DMTs, 77.7% did so by their own choice, 14.5% did so on physician recommendation, 3.8% did so because of insurance denial, 2.7% did so because of a higher copay, and 1.3% because of having no insurance.
“Although the proportion of participants who did not take DMTs due to insurance denial was low, the absolute number of participants was 80, which is relatively high,” Dr. Wang, a research fellow at NARCOMS, said in an interview. “We don’t consider that a small number. The free or discounted drug programs helped a lot of participants obtain DMTs at the relatively early stage of their disease, even those with health insurance. On the other hand, 77.7% of those who were not to taking DMTs had a median Patient Determined Disease Steps of 4, indicating a higher level of disability (using a cane or walking aid) and more likely at a later stage of the disease course. For some of these participants, they may have entered a secondary progressive phase, where there are limited options for DMTs. The contrast between these two groups of participants showed that the free or discounted drug programs not only helped them get access to DMTs, but seemingly also helped them to get DMTs earlier, and thus maximized the benefits of DMTs.”
Of the 398 (6%) respondents who changed their DMT over the 1-year time period studied, nearly half did so for insurance-related reasons, including denial by the insurer (22.4%), higher copay resulting in a decision to skip or split DMTs (12.8%), insurance change (8.3%), and higher copay resulting in a change of DMT (4.3%).
“It’s important for neurologists to know that while their patients are likely to have insurance, a deeper discussion on how they’re going to get their medications covered is warranted,” Stacey Cofield, Ph.D., deputy director of the NARCOMS Coordinating Center, based at the University of Alabama at Birmingham, said in an interview.
In a separate abstract presented at the meeting, Dr. Cofield and her associates reported results from the same Fall 2014 Update survey of 7,601 NARCOMS participants who addressed questions about their DMT status, changes to their DMTs, and how the decision to switch or continue was made. The researchers found that 42.8% of respondents shared decision making with their physicians or spoke with their physicians prior to making a treatment decision (38.8%). They also found that patients currently on a DMT were more likely to engage in shared decision making, compared with those who were not on a DMT (47.4% vs. 33.5%; P < .0001). Patient-centered decision making increased with current worse PDDS (P < .0001).
According to Amber Salter, Ph.D., of NARCOMS, about 3% of MS patients switch DMTs within a 6-month period (Patient Prefer. Adherence 2014:8 971-9), a number that has been increasing in recent years for a variety of reasons. For example, a patient may want to switch from an injectable agent to an oral medication out of perceived convenience, not realizing that being on the oral agent may involve an increased number of office visits for blood testing during treatment, she said.
Difficulty can arise when the patient and the physician both agree on a DMT switch, but the patient’s health insurer says no. “The clinician’s best judgment is, ‘I’ve seen the MRI. There’s activity in the brain. I want to change to a different medication.’ But the insurance company says, ‘You don’t meet our criteria,’ ” said Gary R. Cutter, Ph.D., director of the NARCOMS Coordinating Center. “The patient doesn’t know what to do. The physician can fight [that decision by the insurer], can get involved in that battle. But that’s a different battle that not all physicians have the resources around to tackle. It can be a hassle for both the patient and physician.”
Dr. Cutter noted that MS patients who switch DMTs tend to do worse from a clinical standpoint. “If you look cross-sectionally at data, people who have switched end up with higher levels of disability, and it’s because the physician is reacting to something; it’s not that the drug they switched to is bad,” he said. “These drugs are not cures. They’re meant to slow the progression [of MS].”
NARCOMS is supported by the CMSC and the Foundation of the CMSC. Genentech provided additional support for the survey of treatment decision making. Dr. Cutter disclosed ties to several pharmaceutical companies. The other researchers stated that they had no financial conflicts to disclose.
On Twitter @dougbrunk
INDIANAPOLIS – Although nearly all patients with multiple sclerosis have some form of insurance, 25% of them receive some form of assistance from the pharmaceutical industry in covering the cost of their disease-modifying therapies. In addition, 22% report that their health insurance coverage worsened compared with the prior year.
Those are key findings from a fall 2014 survey of the North American Research Consortium on MS (NARCOMS), a registry with self-reported information on disease-modifying therapies (DMTs), including type, duration of use, changes and reasons for changes, as well as income, insurance, and disease status.
At the annual meeting of the Consortium of Multiple Sclerosis Centers, Guoqiao Wang, Ph.D., and his associates reported findings based on 6,662 (88%) of 7,601 NARCOMS participants who completed the Fall 2014 NARCOMS Update survey, including questions about their health insurance status and DMT choices related to insurance. Of those 6,662 respondents, 99% reported being insured in the prior 6 months, 69% reported that their insurance coverage was unchanged compared with the prior year, and 22% said that their insurance coverage worsened compared with the prior year.
Of the 4,156 (62.4%) respondents who were taking DMTs at the time of the survey, the following financial resources were used to pay for the agents: health insurance copay only (52.1%), free or discounted drug programs (25%), full coverage by health insurance (22.2%), and full payment by the patient (0.7%). Most of those who received assistance from free or discounted drug programs were female (86%), have had their disease for a mean of 7.6 years, tended to have the relapsing-remitting form of MS (71%), and had a median Patient Determined Disease Step of 3 (Gait Disability), suggesting a lower level of disability and most likely an earlier stage of the disease course.
Of the 2,108 (31.6%) respondents who were not taking DMTs, 77.7% did so by their own choice, 14.5% did so on physician recommendation, 3.8% did so because of insurance denial, 2.7% did so because of a higher copay, and 1.3% because of having no insurance.
“Although the proportion of participants who did not take DMTs due to insurance denial was low, the absolute number of participants was 80, which is relatively high,” Dr. Wang, a research fellow at NARCOMS, said in an interview. “We don’t consider that a small number. The free or discounted drug programs helped a lot of participants obtain DMTs at the relatively early stage of their disease, even those with health insurance. On the other hand, 77.7% of those who were not to taking DMTs had a median Patient Determined Disease Steps of 4, indicating a higher level of disability (using a cane or walking aid) and more likely at a later stage of the disease course. For some of these participants, they may have entered a secondary progressive phase, where there are limited options for DMTs. The contrast between these two groups of participants showed that the free or discounted drug programs not only helped them get access to DMTs, but seemingly also helped them to get DMTs earlier, and thus maximized the benefits of DMTs.”
Of the 398 (6%) respondents who changed their DMT over the 1-year time period studied, nearly half did so for insurance-related reasons, including denial by the insurer (22.4%), higher copay resulting in a decision to skip or split DMTs (12.8%), insurance change (8.3%), and higher copay resulting in a change of DMT (4.3%).
“It’s important for neurologists to know that while their patients are likely to have insurance, a deeper discussion on how they’re going to get their medications covered is warranted,” Stacey Cofield, Ph.D., deputy director of the NARCOMS Coordinating Center, based at the University of Alabama at Birmingham, said in an interview.
In a separate abstract presented at the meeting, Dr. Cofield and her associates reported results from the same Fall 2014 Update survey of 7,601 NARCOMS participants who addressed questions about their DMT status, changes to their DMTs, and how the decision to switch or continue was made. The researchers found that 42.8% of respondents shared decision making with their physicians or spoke with their physicians prior to making a treatment decision (38.8%). They also found that patients currently on a DMT were more likely to engage in shared decision making, compared with those who were not on a DMT (47.4% vs. 33.5%; P < .0001). Patient-centered decision making increased with current worse PDDS (P < .0001).
According to Amber Salter, Ph.D., of NARCOMS, about 3% of MS patients switch DMTs within a 6-month period (Patient Prefer. Adherence 2014:8 971-9), a number that has been increasing in recent years for a variety of reasons. For example, a patient may want to switch from an injectable agent to an oral medication out of perceived convenience, not realizing that being on the oral agent may involve an increased number of office visits for blood testing during treatment, she said.
Difficulty can arise when the patient and the physician both agree on a DMT switch, but the patient’s health insurer says no. “The clinician’s best judgment is, ‘I’ve seen the MRI. There’s activity in the brain. I want to change to a different medication.’ But the insurance company says, ‘You don’t meet our criteria,’ ” said Gary R. Cutter, Ph.D., director of the NARCOMS Coordinating Center. “The patient doesn’t know what to do. The physician can fight [that decision by the insurer], can get involved in that battle. But that’s a different battle that not all physicians have the resources around to tackle. It can be a hassle for both the patient and physician.”
Dr. Cutter noted that MS patients who switch DMTs tend to do worse from a clinical standpoint. “If you look cross-sectionally at data, people who have switched end up with higher levels of disability, and it’s because the physician is reacting to something; it’s not that the drug they switched to is bad,” he said. “These drugs are not cures. They’re meant to slow the progression [of MS].”
NARCOMS is supported by the CMSC and the Foundation of the CMSC. Genentech provided additional support for the survey of treatment decision making. Dr. Cutter disclosed ties to several pharmaceutical companies. The other researchers stated that they had no financial conflicts to disclose.
On Twitter @dougbrunk
AT THE CMSC ANNUAL MEETING
Key clinical point: Free or discounted drug programs helped 25% of MS patients obtain DMTs.
Major finding: Among MS patients who were taking DMTs at the time of a survey, the following financial resources were used to pay for the agents: health insurance copay only (52.1%), free or discounted drug programs (25%), full health insurance coverage (22.2%), or full payment by the patient (0.7%).
Data source: Responses from 6,662 of 7,601 North American Research Consortium on MS (NARCOMS) participants who completed the Fall 2014 NARCOMS Update survey.
Disclosures: NARCOMS is supported by the Consortium of Multiple Sclerosis Centers (CMSC) and the Foundation of the CMSC. Genentech provided additional support for the survey of treatment decision making. Dr. Cutter disclosed ties to several pharmaceutical companies. The other researchers stated that they had no financial conflicts to disclose.
CMSC: Many menopausal and MS symptoms overlap
INDIANAPOLIS – About 50% of women with multiple sclerosis are postmenopausal, but objective data about the impact of menopause on the course of multiple sclerosis are lacking.
“We don’t know anything about the impact of menopause on the MS course; there is wide variability in patient-reported outcomes, but nothing written about comorbidities or symptom management,” Dr. Riley Bove, a neurologist at Brigham and Women’s Hospital, Boston, said at the annual meeting of the Consortium of Multiple Sclerosis Centers. “We’ve been working on this. A lot of it is unknown.”
She described menopause is “an opportunity for providers to tackle symptoms and improve well-being and discuss meaningful quality of life and priorities with patients. It can be a good time to talk about these things.”
In a study that Dr. Bove conducted with the online patient-powered research platform PatientsLikeMe, female MS patients were asked to describe the impact of menopause on their disease. Among the themes that emerged were an occasional perimenopausal onset of MS (“menopause and MS symptoms were pretty much simultaneous,” one 58-year-old respondent said); the effect of hot flashes on MS symptoms (“I confused the two, especially hot flashes,” said a 53-year-old woman); and worsening of MS-related disability after menopause, particularly surgical (“Before I stopped taking birth control pills I was working and able to walk and house clean , etc.,” a 53-year-old respondent said. “I had the surgery, and I started to progress toward being completely wheelchair bound.”)
When it comes to solid recommendations for how to manage MS symptoms that overlap with menopause, “we’re in an evidence-free zone,” Dr. Bove said. “Symptoms in MS are kind of like dominoes: You have difficulty sleeping and then your day is off, fatigue is up and your mood is off, and everything can spiral. In the clinic, perimenopausal women often say things like, ‘I feel like I’m falling apart’ or ‘something has to give’ or ‘I need a change.’ ”
Common overlapping symptoms include vasomotor manifestations such as hot flashes, cold flashes, vascular instability, and rapid heartbeat. “The leading mechanistic explanation for the vasomotor symptoms is that abrupt hormone deprivation will result in the loss of negative feedback over hypothalamic NA [noradrenaline] synthesis,” Dr. Bove explained. “The proximity of the hypothalamic thermoregulatory center to luteinizing hormone–releasing hormone-producing areas may also be involved.”
Sleep disturbances and insomnia in menopausal MS patients can impact fatigue and mood. Also, hot flashes can directly exacerbate the MS symptoms, fluctuating over the day or the week.
According to recommendations from the North American Menopause Society, estradiol is the most effective therapy for treating vasomotor symptoms. Other options include selective serotonin reuptake inhibitors (SSRIs) and selective noradrenergic reuptake inhibitors (SNRIs). “Probably the best studied SNRI is venlafaxine,” Dr. Bove said. “It seems to have modest effects on sleep quality and insomnia perimenopausally, as well as on hot flashes.”
Other alternatives include clonidine and gabapentin.
“If a patient wants to use [hormone therapy] for menopausal symptoms, it has to be an individualized approach,” Dr. Bove said. “You have to communicate with the primary care physician to understand what else is going on in this woman’s medical history. The current recommendations are to treat the symptoms with as low a dose as possible for as short a duration as possible. Our MS patients are also at risk for neurodegeneration, for brain volume loss, for cognitive decline, and for worsening function over time.”
With respect to cognition, observational studies have demonstrated that during a certain window of opportunity – defined as within 5 years of the last menstrual period – hormone therapy (HT) may have protective effects against Alzheimer’s disease and against cognitive decline in general. “Beyond this window of time, perhaps due to estrogen receptor down regulation, HT can be harmful, with an increased risk of stroke and dementia reported later on,” she said.
Against this, the Women’s Health Initiative Memory Study (WHIMS) looked at unopposed estrogen, and estrogen and progestin combination, compared with placebo. It found that in women who initiated HT at the age of 65 or older faced an increased risk of dementia from any cause, and of cognitive decline. “This study really put the kibosh on HT as a form of neuroprotection,” Dr. Bove said. “But perhaps it’s unfair to the many patients who are at risk for cognitive decline and neurodegeneration, because the WHIMS did not find an increased risk of adverse cognitive events in women in whom HT was started perimenopausally. Longitudinal, placebo-controlled trials of the effects of HT within the window of opportunity are required to either prove or refute the observational studies that already exist that suggest HT may be neuroprotective. This is an important point to discuss with patients.”
The impact of perimenopausal sleep disturbance on MS symptoms also is unknown. A practical approach to managing sleep disturbance in perimenopausal MS patients is to identify and assess the triggers. “If the bladder symptoms are the major trigger versus mood disturbances such as depression and anxiety, the intervention will be different,” she said. “Consider counseling and/or consultation with a sleep specialist.” Some patients may benefit from pharmacologic treatment to “get them over the hump and get them sleeping better for a little while, versus longer term management if they have a life history of insomnia,” she said. “If the problem is sleep management, you’ll need a drug with a longer half-life. Consider other comorbidities such as anxiety and restless leg syndrome.” Classes of medications to consider include benzodiazepines, nonbenzodiazepines, tricyclic antidepressants, SSRIs and SNRIs.
Mood symptoms commonly overlap in menopausal patients with MS, especially those related to depression and anxiety. “They may be underdiagnosed and undertreated,” Dr. Bove said. “It’s been shown that depression influences the perceived severity of other MS symptoms. Depression is a strong predictor of cognitive and sexual dysfunction, so our perimenopausal MS women have a vulnerability to more severe mood symptoms.” Managing mood symptoms “needs to be multifaceted” and may include psychotherapy to optimize coping abilities, antidepressants, support groups, fatigue and sleep optimization, and social work “to see how employment or financial stressors may be playing a role in a person’s mood.”
In addition, menopausal women may report changes in attention, executive function, multitasking, word finding difficulties, and memory problems, especially in the first year after the final menstrual period. “It’s known that about half of MS patients experience some degree of cognitive impairment,” she said. “Neurocognitive testing may help to identify particular areas of dysfunction that would be amenable to some kind of cognitive rehabilitation.”
Bladder symptoms also can impact postmenopausal patients, especially increasing bladder irritability and incontinence (stress and urge). In MS, “the baseline bladder dysfunction may be magnified,” Dr. Bove said. “If you’re trying to tease out whether the postmenopausal bladder symptoms are from menopause or MS, the MS relapses tend to have more urgency, frequency, and urge incontinence, and the presentation will be more acute. Urodynamic testing can be used to tease this out. The big lifestyle piece that urologists like to hone in on is that people in America drink too much fluid. A practical guideline is that after 3 p.m. just drink for thirst; don’t worry that everything will fall apart if you don’t get your eight glasses of water per day in. If you’re not thirsty, you probably don’t need it.”
While postmenopausal women face an increased risk for osteoporosis, that risk is magnified for MS patients because of the cumulative effect of steroid use – particularly for those who were diagnosed in the pre–disease-modifying-therapy era – being sedentary, and being deconditioned. “Other MS issues such as balance, vision problems, strength or cognitive impairments may all impact gait and compound the risk of falls,” Dr. Bove said. “Osteoporosis prevention and screening should be encouraged in these patients.”
Dr. Bove concluded her presentation by noting that in general, women with disabilities are less likely to be up to date on Pap tests, mammograms, and other important preventive screening tests. “The magnitude of disparities is greater for women with complex limitations,” she said. “Women with MS may have a lower cancer risk, but a larger tumor size at diagnosis.” For example, “is this because the patient is uncomfortable getting on an exam table to get a Pap smear, or is the physician not thinking about other aspects of the person’s life because the focus is on the MS?”
Dr. Bove disclosed that she has received funding from the National Multiple Sclerosis Society, the National Institutes of Health, and from the Harvard Clinical Investigator Training Program.
On Twitter @dougbrunk
INDIANAPOLIS – About 50% of women with multiple sclerosis are postmenopausal, but objective data about the impact of menopause on the course of multiple sclerosis are lacking.
“We don’t know anything about the impact of menopause on the MS course; there is wide variability in patient-reported outcomes, but nothing written about comorbidities or symptom management,” Dr. Riley Bove, a neurologist at Brigham and Women’s Hospital, Boston, said at the annual meeting of the Consortium of Multiple Sclerosis Centers. “We’ve been working on this. A lot of it is unknown.”
She described menopause is “an opportunity for providers to tackle symptoms and improve well-being and discuss meaningful quality of life and priorities with patients. It can be a good time to talk about these things.”
In a study that Dr. Bove conducted with the online patient-powered research platform PatientsLikeMe, female MS patients were asked to describe the impact of menopause on their disease. Among the themes that emerged were an occasional perimenopausal onset of MS (“menopause and MS symptoms were pretty much simultaneous,” one 58-year-old respondent said); the effect of hot flashes on MS symptoms (“I confused the two, especially hot flashes,” said a 53-year-old woman); and worsening of MS-related disability after menopause, particularly surgical (“Before I stopped taking birth control pills I was working and able to walk and house clean , etc.,” a 53-year-old respondent said. “I had the surgery, and I started to progress toward being completely wheelchair bound.”)
When it comes to solid recommendations for how to manage MS symptoms that overlap with menopause, “we’re in an evidence-free zone,” Dr. Bove said. “Symptoms in MS are kind of like dominoes: You have difficulty sleeping and then your day is off, fatigue is up and your mood is off, and everything can spiral. In the clinic, perimenopausal women often say things like, ‘I feel like I’m falling apart’ or ‘something has to give’ or ‘I need a change.’ ”
Common overlapping symptoms include vasomotor manifestations such as hot flashes, cold flashes, vascular instability, and rapid heartbeat. “The leading mechanistic explanation for the vasomotor symptoms is that abrupt hormone deprivation will result in the loss of negative feedback over hypothalamic NA [noradrenaline] synthesis,” Dr. Bove explained. “The proximity of the hypothalamic thermoregulatory center to luteinizing hormone–releasing hormone-producing areas may also be involved.”
Sleep disturbances and insomnia in menopausal MS patients can impact fatigue and mood. Also, hot flashes can directly exacerbate the MS symptoms, fluctuating over the day or the week.
According to recommendations from the North American Menopause Society, estradiol is the most effective therapy for treating vasomotor symptoms. Other options include selective serotonin reuptake inhibitors (SSRIs) and selective noradrenergic reuptake inhibitors (SNRIs). “Probably the best studied SNRI is venlafaxine,” Dr. Bove said. “It seems to have modest effects on sleep quality and insomnia perimenopausally, as well as on hot flashes.”
Other alternatives include clonidine and gabapentin.
“If a patient wants to use [hormone therapy] for menopausal symptoms, it has to be an individualized approach,” Dr. Bove said. “You have to communicate with the primary care physician to understand what else is going on in this woman’s medical history. The current recommendations are to treat the symptoms with as low a dose as possible for as short a duration as possible. Our MS patients are also at risk for neurodegeneration, for brain volume loss, for cognitive decline, and for worsening function over time.”
With respect to cognition, observational studies have demonstrated that during a certain window of opportunity – defined as within 5 years of the last menstrual period – hormone therapy (HT) may have protective effects against Alzheimer’s disease and against cognitive decline in general. “Beyond this window of time, perhaps due to estrogen receptor down regulation, HT can be harmful, with an increased risk of stroke and dementia reported later on,” she said.
Against this, the Women’s Health Initiative Memory Study (WHIMS) looked at unopposed estrogen, and estrogen and progestin combination, compared with placebo. It found that in women who initiated HT at the age of 65 or older faced an increased risk of dementia from any cause, and of cognitive decline. “This study really put the kibosh on HT as a form of neuroprotection,” Dr. Bove said. “But perhaps it’s unfair to the many patients who are at risk for cognitive decline and neurodegeneration, because the WHIMS did not find an increased risk of adverse cognitive events in women in whom HT was started perimenopausally. Longitudinal, placebo-controlled trials of the effects of HT within the window of opportunity are required to either prove or refute the observational studies that already exist that suggest HT may be neuroprotective. This is an important point to discuss with patients.”
The impact of perimenopausal sleep disturbance on MS symptoms also is unknown. A practical approach to managing sleep disturbance in perimenopausal MS patients is to identify and assess the triggers. “If the bladder symptoms are the major trigger versus mood disturbances such as depression and anxiety, the intervention will be different,” she said. “Consider counseling and/or consultation with a sleep specialist.” Some patients may benefit from pharmacologic treatment to “get them over the hump and get them sleeping better for a little while, versus longer term management if they have a life history of insomnia,” she said. “If the problem is sleep management, you’ll need a drug with a longer half-life. Consider other comorbidities such as anxiety and restless leg syndrome.” Classes of medications to consider include benzodiazepines, nonbenzodiazepines, tricyclic antidepressants, SSRIs and SNRIs.
Mood symptoms commonly overlap in menopausal patients with MS, especially those related to depression and anxiety. “They may be underdiagnosed and undertreated,” Dr. Bove said. “It’s been shown that depression influences the perceived severity of other MS symptoms. Depression is a strong predictor of cognitive and sexual dysfunction, so our perimenopausal MS women have a vulnerability to more severe mood symptoms.” Managing mood symptoms “needs to be multifaceted” and may include psychotherapy to optimize coping abilities, antidepressants, support groups, fatigue and sleep optimization, and social work “to see how employment or financial stressors may be playing a role in a person’s mood.”
In addition, menopausal women may report changes in attention, executive function, multitasking, word finding difficulties, and memory problems, especially in the first year after the final menstrual period. “It’s known that about half of MS patients experience some degree of cognitive impairment,” she said. “Neurocognitive testing may help to identify particular areas of dysfunction that would be amenable to some kind of cognitive rehabilitation.”
Bladder symptoms also can impact postmenopausal patients, especially increasing bladder irritability and incontinence (stress and urge). In MS, “the baseline bladder dysfunction may be magnified,” Dr. Bove said. “If you’re trying to tease out whether the postmenopausal bladder symptoms are from menopause or MS, the MS relapses tend to have more urgency, frequency, and urge incontinence, and the presentation will be more acute. Urodynamic testing can be used to tease this out. The big lifestyle piece that urologists like to hone in on is that people in America drink too much fluid. A practical guideline is that after 3 p.m. just drink for thirst; don’t worry that everything will fall apart if you don’t get your eight glasses of water per day in. If you’re not thirsty, you probably don’t need it.”
While postmenopausal women face an increased risk for osteoporosis, that risk is magnified for MS patients because of the cumulative effect of steroid use – particularly for those who were diagnosed in the pre–disease-modifying-therapy era – being sedentary, and being deconditioned. “Other MS issues such as balance, vision problems, strength or cognitive impairments may all impact gait and compound the risk of falls,” Dr. Bove said. “Osteoporosis prevention and screening should be encouraged in these patients.”
Dr. Bove concluded her presentation by noting that in general, women with disabilities are less likely to be up to date on Pap tests, mammograms, and other important preventive screening tests. “The magnitude of disparities is greater for women with complex limitations,” she said. “Women with MS may have a lower cancer risk, but a larger tumor size at diagnosis.” For example, “is this because the patient is uncomfortable getting on an exam table to get a Pap smear, or is the physician not thinking about other aspects of the person’s life because the focus is on the MS?”
Dr. Bove disclosed that she has received funding from the National Multiple Sclerosis Society, the National Institutes of Health, and from the Harvard Clinical Investigator Training Program.
On Twitter @dougbrunk
INDIANAPOLIS – About 50% of women with multiple sclerosis are postmenopausal, but objective data about the impact of menopause on the course of multiple sclerosis are lacking.
“We don’t know anything about the impact of menopause on the MS course; there is wide variability in patient-reported outcomes, but nothing written about comorbidities or symptom management,” Dr. Riley Bove, a neurologist at Brigham and Women’s Hospital, Boston, said at the annual meeting of the Consortium of Multiple Sclerosis Centers. “We’ve been working on this. A lot of it is unknown.”
She described menopause is “an opportunity for providers to tackle symptoms and improve well-being and discuss meaningful quality of life and priorities with patients. It can be a good time to talk about these things.”
In a study that Dr. Bove conducted with the online patient-powered research platform PatientsLikeMe, female MS patients were asked to describe the impact of menopause on their disease. Among the themes that emerged were an occasional perimenopausal onset of MS (“menopause and MS symptoms were pretty much simultaneous,” one 58-year-old respondent said); the effect of hot flashes on MS symptoms (“I confused the two, especially hot flashes,” said a 53-year-old woman); and worsening of MS-related disability after menopause, particularly surgical (“Before I stopped taking birth control pills I was working and able to walk and house clean , etc.,” a 53-year-old respondent said. “I had the surgery, and I started to progress toward being completely wheelchair bound.”)
When it comes to solid recommendations for how to manage MS symptoms that overlap with menopause, “we’re in an evidence-free zone,” Dr. Bove said. “Symptoms in MS are kind of like dominoes: You have difficulty sleeping and then your day is off, fatigue is up and your mood is off, and everything can spiral. In the clinic, perimenopausal women often say things like, ‘I feel like I’m falling apart’ or ‘something has to give’ or ‘I need a change.’ ”
Common overlapping symptoms include vasomotor manifestations such as hot flashes, cold flashes, vascular instability, and rapid heartbeat. “The leading mechanistic explanation for the vasomotor symptoms is that abrupt hormone deprivation will result in the loss of negative feedback over hypothalamic NA [noradrenaline] synthesis,” Dr. Bove explained. “The proximity of the hypothalamic thermoregulatory center to luteinizing hormone–releasing hormone-producing areas may also be involved.”
Sleep disturbances and insomnia in menopausal MS patients can impact fatigue and mood. Also, hot flashes can directly exacerbate the MS symptoms, fluctuating over the day or the week.
According to recommendations from the North American Menopause Society, estradiol is the most effective therapy for treating vasomotor symptoms. Other options include selective serotonin reuptake inhibitors (SSRIs) and selective noradrenergic reuptake inhibitors (SNRIs). “Probably the best studied SNRI is venlafaxine,” Dr. Bove said. “It seems to have modest effects on sleep quality and insomnia perimenopausally, as well as on hot flashes.”
Other alternatives include clonidine and gabapentin.
“If a patient wants to use [hormone therapy] for menopausal symptoms, it has to be an individualized approach,” Dr. Bove said. “You have to communicate with the primary care physician to understand what else is going on in this woman’s medical history. The current recommendations are to treat the symptoms with as low a dose as possible for as short a duration as possible. Our MS patients are also at risk for neurodegeneration, for brain volume loss, for cognitive decline, and for worsening function over time.”
With respect to cognition, observational studies have demonstrated that during a certain window of opportunity – defined as within 5 years of the last menstrual period – hormone therapy (HT) may have protective effects against Alzheimer’s disease and against cognitive decline in general. “Beyond this window of time, perhaps due to estrogen receptor down regulation, HT can be harmful, with an increased risk of stroke and dementia reported later on,” she said.
Against this, the Women’s Health Initiative Memory Study (WHIMS) looked at unopposed estrogen, and estrogen and progestin combination, compared with placebo. It found that in women who initiated HT at the age of 65 or older faced an increased risk of dementia from any cause, and of cognitive decline. “This study really put the kibosh on HT as a form of neuroprotection,” Dr. Bove said. “But perhaps it’s unfair to the many patients who are at risk for cognitive decline and neurodegeneration, because the WHIMS did not find an increased risk of adverse cognitive events in women in whom HT was started perimenopausally. Longitudinal, placebo-controlled trials of the effects of HT within the window of opportunity are required to either prove or refute the observational studies that already exist that suggest HT may be neuroprotective. This is an important point to discuss with patients.”
The impact of perimenopausal sleep disturbance on MS symptoms also is unknown. A practical approach to managing sleep disturbance in perimenopausal MS patients is to identify and assess the triggers. “If the bladder symptoms are the major trigger versus mood disturbances such as depression and anxiety, the intervention will be different,” she said. “Consider counseling and/or consultation with a sleep specialist.” Some patients may benefit from pharmacologic treatment to “get them over the hump and get them sleeping better for a little while, versus longer term management if they have a life history of insomnia,” she said. “If the problem is sleep management, you’ll need a drug with a longer half-life. Consider other comorbidities such as anxiety and restless leg syndrome.” Classes of medications to consider include benzodiazepines, nonbenzodiazepines, tricyclic antidepressants, SSRIs and SNRIs.
Mood symptoms commonly overlap in menopausal patients with MS, especially those related to depression and anxiety. “They may be underdiagnosed and undertreated,” Dr. Bove said. “It’s been shown that depression influences the perceived severity of other MS symptoms. Depression is a strong predictor of cognitive and sexual dysfunction, so our perimenopausal MS women have a vulnerability to more severe mood symptoms.” Managing mood symptoms “needs to be multifaceted” and may include psychotherapy to optimize coping abilities, antidepressants, support groups, fatigue and sleep optimization, and social work “to see how employment or financial stressors may be playing a role in a person’s mood.”
In addition, menopausal women may report changes in attention, executive function, multitasking, word finding difficulties, and memory problems, especially in the first year after the final menstrual period. “It’s known that about half of MS patients experience some degree of cognitive impairment,” she said. “Neurocognitive testing may help to identify particular areas of dysfunction that would be amenable to some kind of cognitive rehabilitation.”
Bladder symptoms also can impact postmenopausal patients, especially increasing bladder irritability and incontinence (stress and urge). In MS, “the baseline bladder dysfunction may be magnified,” Dr. Bove said. “If you’re trying to tease out whether the postmenopausal bladder symptoms are from menopause or MS, the MS relapses tend to have more urgency, frequency, and urge incontinence, and the presentation will be more acute. Urodynamic testing can be used to tease this out. The big lifestyle piece that urologists like to hone in on is that people in America drink too much fluid. A practical guideline is that after 3 p.m. just drink for thirst; don’t worry that everything will fall apart if you don’t get your eight glasses of water per day in. If you’re not thirsty, you probably don’t need it.”
While postmenopausal women face an increased risk for osteoporosis, that risk is magnified for MS patients because of the cumulative effect of steroid use – particularly for those who were diagnosed in the pre–disease-modifying-therapy era – being sedentary, and being deconditioned. “Other MS issues such as balance, vision problems, strength or cognitive impairments may all impact gait and compound the risk of falls,” Dr. Bove said. “Osteoporosis prevention and screening should be encouraged in these patients.”
Dr. Bove concluded her presentation by noting that in general, women with disabilities are less likely to be up to date on Pap tests, mammograms, and other important preventive screening tests. “The magnitude of disparities is greater for women with complex limitations,” she said. “Women with MS may have a lower cancer risk, but a larger tumor size at diagnosis.” For example, “is this because the patient is uncomfortable getting on an exam table to get a Pap smear, or is the physician not thinking about other aspects of the person’s life because the focus is on the MS?”
Dr. Bove disclosed that she has received funding from the National Multiple Sclerosis Society, the National Institutes of Health, and from the Harvard Clinical Investigator Training Program.
On Twitter @dougbrunk
EXPERT ANALYSIS AT THE CMSC ANNUAL MEETING
Mark S. Freedman, HBSc, MSc, MD
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
Mark S. Freedman, HBSc, MSc, MD
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
Samuel F. Hunter, MD, PhD
Life Expectancy and Multiple Sclerosis
Life expectancy in patients with multiple sclerosis (MS) is approximately 7.5 years shorter than those without MS and comorbidities increase the risk of mortality, according to a population-based study of 5,797 people with MS and 28,807 age- and sex-matched controls.
Investigators used Cox proportional hazards regression to evaluate the association between comorbidity status and mortality and found:
• Median lifespan among MS patients is 75.9 years, compared with 83.4 years in the control group.
• MS was associated with a 2-fold increased risk of mortality.
• Diabetes, ischemic heart disease, and chronic lung disease increased death hazards in both populations, however, the association was lower in the MS group.
• Mortality rates from infectious and respiratory diseases were higher in the MS group.
• The most common cause of death in the MS group was nervous- or circulatory-system diseases.
Citation: Marrie RA, Elliott L, Marriott J, et al. Effect of comorbidity on mortality in multiple sclerosis. Neurology. 2015. pii:10.1212/WNL.0000000000001718.
Commentary: Multiple Sclerosis is considered a disease of the young. However, the young grow older and accumulate the burdens of living with other illness as well. Having one chronic disease does not prevent you from having another chronic illness and experiencing problems related to both. The more illnesses you accumulate, the harder it becomes to live life without disability and to live a long life. As much as we consider MS a disease that does not shorten life expectancy, that is simply not the case. Those with MS can experience a shorter lifespan and the concurrent complications related to infection and the illness itself clearly can result in a shortened lifespan. This article should reinforce the need and make us double our efforts to diagnose and treat MS early as well as effectively to prevent the long term premature morbidity and mortality of ineffectively and untreated MS. — Mark Gudesblatt, MD, Medical Director of the Comprehensive MS Care Center at South Shore Neurologic Associates in Islip, NY
Life expectancy in patients with multiple sclerosis (MS) is approximately 7.5 years shorter than those without MS and comorbidities increase the risk of mortality, according to a population-based study of 5,797 people with MS and 28,807 age- and sex-matched controls.
Investigators used Cox proportional hazards regression to evaluate the association between comorbidity status and mortality and found:
• Median lifespan among MS patients is 75.9 years, compared with 83.4 years in the control group.
• MS was associated with a 2-fold increased risk of mortality.
• Diabetes, ischemic heart disease, and chronic lung disease increased death hazards in both populations, however, the association was lower in the MS group.
• Mortality rates from infectious and respiratory diseases were higher in the MS group.
• The most common cause of death in the MS group was nervous- or circulatory-system diseases.
Citation: Marrie RA, Elliott L, Marriott J, et al. Effect of comorbidity on mortality in multiple sclerosis. Neurology. 2015. pii:10.1212/WNL.0000000000001718.
Commentary: Multiple Sclerosis is considered a disease of the young. However, the young grow older and accumulate the burdens of living with other illness as well. Having one chronic disease does not prevent you from having another chronic illness and experiencing problems related to both. The more illnesses you accumulate, the harder it becomes to live life without disability and to live a long life. As much as we consider MS a disease that does not shorten life expectancy, that is simply not the case. Those with MS can experience a shorter lifespan and the concurrent complications related to infection and the illness itself clearly can result in a shortened lifespan. This article should reinforce the need and make us double our efforts to diagnose and treat MS early as well as effectively to prevent the long term premature morbidity and mortality of ineffectively and untreated MS. — Mark Gudesblatt, MD, Medical Director of the Comprehensive MS Care Center at South Shore Neurologic Associates in Islip, NY
Life expectancy in patients with multiple sclerosis (MS) is approximately 7.5 years shorter than those without MS and comorbidities increase the risk of mortality, according to a population-based study of 5,797 people with MS and 28,807 age- and sex-matched controls.
Investigators used Cox proportional hazards regression to evaluate the association between comorbidity status and mortality and found:
• Median lifespan among MS patients is 75.9 years, compared with 83.4 years in the control group.
• MS was associated with a 2-fold increased risk of mortality.
• Diabetes, ischemic heart disease, and chronic lung disease increased death hazards in both populations, however, the association was lower in the MS group.
• Mortality rates from infectious and respiratory diseases were higher in the MS group.
• The most common cause of death in the MS group was nervous- or circulatory-system diseases.
Citation: Marrie RA, Elliott L, Marriott J, et al. Effect of comorbidity on mortality in multiple sclerosis. Neurology. 2015. pii:10.1212/WNL.0000000000001718.
Commentary: Multiple Sclerosis is considered a disease of the young. However, the young grow older and accumulate the burdens of living with other illness as well. Having one chronic disease does not prevent you from having another chronic illness and experiencing problems related to both. The more illnesses you accumulate, the harder it becomes to live life without disability and to live a long life. As much as we consider MS a disease that does not shorten life expectancy, that is simply not the case. Those with MS can experience a shorter lifespan and the concurrent complications related to infection and the illness itself clearly can result in a shortened lifespan. This article should reinforce the need and make us double our efforts to diagnose and treat MS early as well as effectively to prevent the long term premature morbidity and mortality of ineffectively and untreated MS. — Mark Gudesblatt, MD, Medical Director of the Comprehensive MS Care Center at South Shore Neurologic Associates in Islip, NY
When Patients Don’t Respond to Interferon-β
A genetic variant may hinder the effectiveness of interferon-β (IFNβ) in some patients with multiple sclerosis (MS), a genome-wide association study reports.
Researchers found an association between rs9828519, an intronic variant in SLC9A9, and patients with relapsing forms of MS who do not respond to IFNβ treatment. This discovery was then validated in a meta-analysis of 3 independent cohorts.
The study authors suggest the genetic marker can be used as a successful pharmacogenetic screen, creating a more personalized approach to MS treatment.
Citation: Esposito F, Sorosina M, Ottoboni L, et al. A pharmacogenetic study implicates SLC9a9 in multiple sclerosis disease activity. Ann Neurol. 2015. doi:10.1002/ana.24429.
A genetic variant may hinder the effectiveness of interferon-β (IFNβ) in some patients with multiple sclerosis (MS), a genome-wide association study reports.
Researchers found an association between rs9828519, an intronic variant in SLC9A9, and patients with relapsing forms of MS who do not respond to IFNβ treatment. This discovery was then validated in a meta-analysis of 3 independent cohorts.
The study authors suggest the genetic marker can be used as a successful pharmacogenetic screen, creating a more personalized approach to MS treatment.
Citation: Esposito F, Sorosina M, Ottoboni L, et al. A pharmacogenetic study implicates SLC9a9 in multiple sclerosis disease activity. Ann Neurol. 2015. doi:10.1002/ana.24429.
A genetic variant may hinder the effectiveness of interferon-β (IFNβ) in some patients with multiple sclerosis (MS), a genome-wide association study reports.
Researchers found an association between rs9828519, an intronic variant in SLC9A9, and patients with relapsing forms of MS who do not respond to IFNβ treatment. This discovery was then validated in a meta-analysis of 3 independent cohorts.
The study authors suggest the genetic marker can be used as a successful pharmacogenetic screen, creating a more personalized approach to MS treatment.
Citation: Esposito F, Sorosina M, Ottoboni L, et al. A pharmacogenetic study implicates SLC9a9 in multiple sclerosis disease activity. Ann Neurol. 2015. doi:10.1002/ana.24429.
Factors Linking Optic Neuritis to MS Risk
In children with isolated optic neuritis, 3 independent biomarkers are strongly associated with progression to multiple sclerosis, according to a retrospective analysis of 357 children with the condition.
Investigators used multiple Cox proportional regressions to determine the following hazard ratios (HR):
• abnormal cranial magnetic resonance imaging (cMRI), 5.94
• the presence of cerebrosnial fluid immunoglobulin G oligoclonal bands (OCB), 3.69
• age, 1.08 per year of age
• cMRI and OCB positivity combined, 26.84
Neither sex nor laterality (unilateral or bilateral) were associated with an increased rate of disease progression to MS.
Citation: Heussinger N, Kontopantelis E, Gburek-Augustat J, et al; for GRACE-MS (German-speaking Research Alliance for ChildrEn with Multiple Sclerosis). Oligoclonal bands predict multiple sclerosis in children with optic neuritis. Ann Neurol. 2015. doi:10.1002/ana.24409.
In children with isolated optic neuritis, 3 independent biomarkers are strongly associated with progression to multiple sclerosis, according to a retrospective analysis of 357 children with the condition.
Investigators used multiple Cox proportional regressions to determine the following hazard ratios (HR):
• abnormal cranial magnetic resonance imaging (cMRI), 5.94
• the presence of cerebrosnial fluid immunoglobulin G oligoclonal bands (OCB), 3.69
• age, 1.08 per year of age
• cMRI and OCB positivity combined, 26.84
Neither sex nor laterality (unilateral or bilateral) were associated with an increased rate of disease progression to MS.
Citation: Heussinger N, Kontopantelis E, Gburek-Augustat J, et al; for GRACE-MS (German-speaking Research Alliance for ChildrEn with Multiple Sclerosis). Oligoclonal bands predict multiple sclerosis in children with optic neuritis. Ann Neurol. 2015. doi:10.1002/ana.24409.
In children with isolated optic neuritis, 3 independent biomarkers are strongly associated with progression to multiple sclerosis, according to a retrospective analysis of 357 children with the condition.
Investigators used multiple Cox proportional regressions to determine the following hazard ratios (HR):
• abnormal cranial magnetic resonance imaging (cMRI), 5.94
• the presence of cerebrosnial fluid immunoglobulin G oligoclonal bands (OCB), 3.69
• age, 1.08 per year of age
• cMRI and OCB positivity combined, 26.84
Neither sex nor laterality (unilateral or bilateral) were associated with an increased rate of disease progression to MS.
Citation: Heussinger N, Kontopantelis E, Gburek-Augustat J, et al; for GRACE-MS (German-speaking Research Alliance for ChildrEn with Multiple Sclerosis). Oligoclonal bands predict multiple sclerosis in children with optic neuritis. Ann Neurol. 2015. doi:10.1002/ana.24409.
Does Education Status Impact MS Risk?
Higher levels of education are associated with a decreased risk of multiple sclerosis (MS) independent of other established risk factors, according to the Environmental Factors in MS (EnvIMS) study.
The case-control study of 953 MS patients and 1,717 healthy controls reported education level and history of exposure to putative environmental risk factors, including known risk factors of smoking, infective mononucleosis, vitamin D levels, and body size.
In comparison to the lowest level of education, higher levels of education was associated with a decreased MS risk odds ratio of 0.53, a risk that was only moderately reduced after adjusting for other risk factors. The study authors note this suggests factors linked to lower socioeconomic status aside from established risks may play a role in MS.
Citation: Bjørnevik K, Riise T, Cortese M, et al. Level of education and multiple sclerosis risk after adjustment for known risk factors: The EnvIMS study. Mult Scler. 2015. pii:1352458515579444.
Higher levels of education are associated with a decreased risk of multiple sclerosis (MS) independent of other established risk factors, according to the Environmental Factors in MS (EnvIMS) study.
The case-control study of 953 MS patients and 1,717 healthy controls reported education level and history of exposure to putative environmental risk factors, including known risk factors of smoking, infective mononucleosis, vitamin D levels, and body size.
In comparison to the lowest level of education, higher levels of education was associated with a decreased MS risk odds ratio of 0.53, a risk that was only moderately reduced after adjusting for other risk factors. The study authors note this suggests factors linked to lower socioeconomic status aside from established risks may play a role in MS.
Citation: Bjørnevik K, Riise T, Cortese M, et al. Level of education and multiple sclerosis risk after adjustment for known risk factors: The EnvIMS study. Mult Scler. 2015. pii:1352458515579444.
Higher levels of education are associated with a decreased risk of multiple sclerosis (MS) independent of other established risk factors, according to the Environmental Factors in MS (EnvIMS) study.
The case-control study of 953 MS patients and 1,717 healthy controls reported education level and history of exposure to putative environmental risk factors, including known risk factors of smoking, infective mononucleosis, vitamin D levels, and body size.
In comparison to the lowest level of education, higher levels of education was associated with a decreased MS risk odds ratio of 0.53, a risk that was only moderately reduced after adjusting for other risk factors. The study authors note this suggests factors linked to lower socioeconomic status aside from established risks may play a role in MS.
Citation: Bjørnevik K, Riise T, Cortese M, et al. Level of education and multiple sclerosis risk after adjustment for known risk factors: The EnvIMS study. Mult Scler. 2015. pii:1352458515579444.
Variation in Brain Iron Levels in MS and CIS
Iron accumulation in the basal ganglia is more pronounced in the early phases of clinically isolated syndrome (CIS) and definite multiple sclerosis (MS), but short-term changes in iron concentration are not associated with disease activity or changes in disability, a longitudinal 3T MRI study of 144 patients reports.
Investigators followed patients both clinically and with 3T MRI for an average of 3 years and found:
• Subcortical gray matter iron deposition was higher in MS than CIS at baseline.
• In CIS, R2* rates increased in the globus pallidus, putamen, and caudate nucleus, but decreased in the thalamus.
• In MS, R2* rates increased in the putamen, remained stable in the globus pallidus and caudate nucleus, and decreased in the thalamus.
Citation: Khalil M, Langkammer C, Pichler A, et al. Dynamics of brain iron levels in multiple sclerosis: A longitudinal 3T MRI study. Neurology. 2015. pii:10.1212/WNL.0000000000001679. [Epub ahead of print]
Iron accumulation in the basal ganglia is more pronounced in the early phases of clinically isolated syndrome (CIS) and definite multiple sclerosis (MS), but short-term changes in iron concentration are not associated with disease activity or changes in disability, a longitudinal 3T MRI study of 144 patients reports.
Investigators followed patients both clinically and with 3T MRI for an average of 3 years and found:
• Subcortical gray matter iron deposition was higher in MS than CIS at baseline.
• In CIS, R2* rates increased in the globus pallidus, putamen, and caudate nucleus, but decreased in the thalamus.
• In MS, R2* rates increased in the putamen, remained stable in the globus pallidus and caudate nucleus, and decreased in the thalamus.
Citation: Khalil M, Langkammer C, Pichler A, et al. Dynamics of brain iron levels in multiple sclerosis: A longitudinal 3T MRI study. Neurology. 2015. pii:10.1212/WNL.0000000000001679. [Epub ahead of print]
Iron accumulation in the basal ganglia is more pronounced in the early phases of clinically isolated syndrome (CIS) and definite multiple sclerosis (MS), but short-term changes in iron concentration are not associated with disease activity or changes in disability, a longitudinal 3T MRI study of 144 patients reports.
Investigators followed patients both clinically and with 3T MRI for an average of 3 years and found:
• Subcortical gray matter iron deposition was higher in MS than CIS at baseline.
• In CIS, R2* rates increased in the globus pallidus, putamen, and caudate nucleus, but decreased in the thalamus.
• In MS, R2* rates increased in the putamen, remained stable in the globus pallidus and caudate nucleus, and decreased in the thalamus.
Citation: Khalil M, Langkammer C, Pichler A, et al. Dynamics of brain iron levels in multiple sclerosis: A longitudinal 3T MRI study. Neurology. 2015. pii:10.1212/WNL.0000000000001679. [Epub ahead of print]