Multiple Sclerosis Hub

INDIANAPOLIS—Most patients with relapsing-remitting multiple sclerosis (MS) remain free of new MRI activity for four years after initiating treatment with alemtuzumab, according to data presented at the 2015 CMSC Annual Meeting. Alemtuzumab also appears to slow the rate of brain volume loss, compared with interferon beta. The drug’s durable effects may result from the distinct pattern of lymphocyte depletion and repopulation that follows treatment, said Anthony Traboulsee, MD, Associate Professor of Neurology at the University of British Columbia in Vancouver.

The data result from four-year follow-up of participants in the CARE-MS II trial. In that study, patients with relapsing-remitting MS who had had an inadequate response to prior therapy (defined as at least one relapse) were randomized to alemtuzumab or subcutaneous interferon beta-1a. After two years, patients receiving alemtuzumab had a 49% decrease in annualized relapse rate and a 42% decrease in six-month sustained accumulation of disability, compared with patients who received interferon beta-1a. In addition, more patients in the alemtuzumab group were free of MRI activity, compared with the interferon group.

The open-label extension study was designed to observe the effect of alemtuzumab on MRI outcomes over four years. In this study, patients randomized to interferon had the option of receiving alemtuzumab, and patients randomized to alemtuzumab were allowed to receive additional treatment if they had breakthrough clinical or MRI activity.

About 93% of the original alemtuzumab group entered the extension study. Approximately 68% of these participants were clinically and radiologically stable and did not require further treatments during the two years of the extension. The proportion of participants receiving alemtuzumab who were free of MRI activity was 68.4% in Year 3 and 69.9% in Year 4. This proportion remained stable, compared with that of the original study. The proportion of patients receiving alemtuzumab with no evidence of disease activity (ie, clinical or MRI activity) was 52.9% at Year 3 and 54.5% at Year 4.

The median yearly loss in brain volume was smaller in Years 3 and 4 than during the original study for patients receiving alemtuzumab. Median yearly brain volume change was –0.22% at Year 2, –0.10% at Year 3, and –0.19% at Year 4. “These results reflect a reduction in focal inflammation with alemtuzumab treatment,” said Dr. Traboulsee. “Together, these findings indicate that alemtuzumab represents a novel and durable treatment approach for relapsing-remitting MS.”

—Erik Greb

INDIANAPOLIS—Most patients with relapsing-remitting multiple sclerosis (MS) remain free of new MRI activity for four years after initiating treatment with alemtuzumab, according to data presented at the 2015 CMSC Annual Meeting. Alemtuzumab also appears to slow the rate of brain volume loss, compared with interferon beta. The drug’s durable effects may result from the distinct pattern of lymphocyte depletion and repopulation that follows treatment, said Anthony Traboulsee, MD, Associate Professor of Neurology at the University of British Columbia in Vancouver.

The data result from four-year follow-up of participants in the CARE-MS II trial. In that study, patients with relapsing-remitting MS who had had an inadequate response to prior therapy (defined as at least one relapse) were randomized to alemtuzumab or subcutaneous interferon beta-1a. After two years, patients receiving alemtuzumab had a 49% decrease in annualized relapse rate and a 42% decrease in six-month sustained accumulation of disability, compared with patients who received interferon beta-1a. In addition, more patients in the alemtuzumab group were free of MRI activity, compared with the interferon group.

The open-label extension study was designed to observe the effect of alemtuzumab on MRI outcomes over four years. In this study, patients randomized to interferon had the option of receiving alemtuzumab, and patients randomized to alemtuzumab were allowed to receive additional treatment if they had breakthrough clinical or MRI activity.

About 93% of the original alemtuzumab group entered the extension study. Approximately 68% of these participants were clinically and radiologically stable and did not require further treatments during the two years of the extension. The proportion of participants receiving alemtuzumab who were free of MRI activity was 68.4% in Year 3 and 69.9% in Year 4. This proportion remained stable, compared with that of the original study. The proportion of patients receiving alemtuzumab with no evidence of disease activity (ie, clinical or MRI activity) was 52.9% at Year 3 and 54.5% at Year 4.

The median yearly loss in brain volume was smaller in Years 3 and 4 than during the original study for patients receiving alemtuzumab. Median yearly brain volume change was –0.22% at Year 2, –0.10% at Year 3, and –0.19% at Year 4. “These results reflect a reduction in focal inflammation with alemtuzumab treatment,” said Dr. Traboulsee. “Together, these findings indicate that alemtuzumab represents a novel and durable treatment approach for relapsing-remitting MS.”

—Erik Greb

INDIANAPOLIS—Most patients with relapsing-remitting multiple sclerosis (MS) remain free of new MRI activity for four years after initiating treatment with alemtuzumab, according to data presented at the 2015 CMSC Annual Meeting. Alemtuzumab also appears to slow the rate of brain volume loss, compared with interferon beta. The drug’s durable effects may result from the distinct pattern of lymphocyte depletion and repopulation that follows treatment, said Anthony Traboulsee, MD, Associate Professor of Neurology at the University of British Columbia in Vancouver.

The data result from four-year follow-up of participants in the CARE-MS II trial. In that study, patients with relapsing-remitting MS who had had an inadequate response to prior therapy (defined as at least one relapse) were randomized to alemtuzumab or subcutaneous interferon beta-1a. After two years, patients receiving alemtuzumab had a 49% decrease in annualized relapse rate and a 42% decrease in six-month sustained accumulation of disability, compared with patients who received interferon beta-1a. In addition, more patients in the alemtuzumab group were free of MRI activity, compared with the interferon group.

The open-label extension study was designed to observe the effect of alemtuzumab on MRI outcomes over four years. In this study, patients randomized to interferon had the option of receiving alemtuzumab, and patients randomized to alemtuzumab were allowed to receive additional treatment if they had breakthrough clinical or MRI activity.

About 93% of the original alemtuzumab group entered the extension study. Approximately 68% of these participants were clinically and radiologically stable and did not require further treatments during the two years of the extension. The proportion of participants receiving alemtuzumab who were free of MRI activity was 68.4% in Year 3 and 69.9% in Year 4. This proportion remained stable, compared with that of the original study. The proportion of patients receiving alemtuzumab with no evidence of disease activity (ie, clinical or MRI activity) was 52.9% at Year 3 and 54.5% at Year 4.

The median yearly loss in brain volume was smaller in Years 3 and 4 than during the original study for patients receiving alemtuzumab. Median yearly brain volume change was –0.22% at Year 2, –0.10% at Year 3, and –0.19% at Year 4. “These results reflect a reduction in focal inflammation with alemtuzumab treatment,” said Dr. Traboulsee. “Together, these findings indicate that alemtuzumab represents a novel and durable treatment approach for relapsing-remitting MS.”

—Erik Greb

INDIANAPOLIS—A majority of patients remain stable when switching from natalizumab to dimethyl fumarate, according to data presented at the 2015 CMSC Annual Meeting. Factors such as sex, age, and duration of natalizumab treatment may predict the probability of a successful transition, reported lead author Faria S. Amjad, MD, of Georgetown University Hospital in Washington, DC, and research colleagues.

Natalizumab is a monoclonal antibody that prevents entry of leukocytes into the CNS. This mechanism of action has made it one of the most effective therapies against multiple sclerosis (MS). However, natalizumab’s use is limited by its risk of progressive multifocal leukoencephalopathy (PML). Moreover, switching from natalizumab to another therapeutic agent is made even more complex, as there is an increased risk of rebound inflammation. Dimethyl fumarate is an oral agent that offers a therapeutic alternative to patients stopping natalizumab. However, the safety and efficacy of this switch have not been studied.

To assess the stability of patients switched from natalizumab to dimethyl fumarate, Dr. Amjad and colleagues conducted a telephone survey and chart review for 66 patients with relapsing-remitting MS who had been switched from natalizumab to dimethyl fumarate. Factors analyzed included age, gender, duration on natalizumab, and duration on dimethyl fumarate.

A total of 66 patients were surveyed; 47 (71.22%) remained stable when switched to dimethyl fumarate, and 19 (28.78%) were found to be unstable on dimethyl fumarate. While the findings were not statistically significant, several trends were noted. Female patients were 2.9 times more likely to be unstable, compared with males. Patients younger than 60 were 1.8 times more likely to be unstable, compared with patients older than 60. Patients on natalizumab for less than two years were 2.4 times more likely to be unstable, compared with patients on natulizumab for more than two years. Patients who have an eight-week or less gap between natulizumab and dimethyl fumarate are just as likely to develop instability as patients with more than an eight-week gap between treatments. Patients who are on dimethyl fumarate for less than six months are 0.6 times less likely to be unstable than patients on dimethyl fumarate for longer than six months. In other words, patients on dimethyl fumarate for longer than six months are 1.7 times more likely to be unstable.

According to the researchers, an extension of this study will look at MRI changes and relapse rate after a patient has stopped natalizumab therapy and switched to dimethyl fumarate.

INDIANAPOLIS—A majority of patients remain stable when switching from natalizumab to dimethyl fumarate, according to data presented at the 2015 CMSC Annual Meeting. Factors such as sex, age, and duration of natalizumab treatment may predict the probability of a successful transition, reported lead author Faria S. Amjad, MD, of Georgetown University Hospital in Washington, DC, and research colleagues.

Natalizumab is a monoclonal antibody that prevents entry of leukocytes into the CNS. This mechanism of action has made it one of the most effective therapies against multiple sclerosis (MS). However, natalizumab’s use is limited by its risk of progressive multifocal leukoencephalopathy (PML). Moreover, switching from natalizumab to another therapeutic agent is made even more complex, as there is an increased risk of rebound inflammation. Dimethyl fumarate is an oral agent that offers a therapeutic alternative to patients stopping natalizumab. However, the safety and efficacy of this switch have not been studied.

To assess the stability of patients switched from natalizumab to dimethyl fumarate, Dr. Amjad and colleagues conducted a telephone survey and chart review for 66 patients with relapsing-remitting MS who had been switched from natalizumab to dimethyl fumarate. Factors analyzed included age, gender, duration on natalizumab, and duration on dimethyl fumarate.

A total of 66 patients were surveyed; 47 (71.22%) remained stable when switched to dimethyl fumarate, and 19 (28.78%) were found to be unstable on dimethyl fumarate. While the findings were not statistically significant, several trends were noted. Female patients were 2.9 times more likely to be unstable, compared with males. Patients younger than 60 were 1.8 times more likely to be unstable, compared with patients older than 60. Patients on natalizumab for less than two years were 2.4 times more likely to be unstable, compared with patients on natulizumab for more than two years. Patients who have an eight-week or less gap between natulizumab and dimethyl fumarate are just as likely to develop instability as patients with more than an eight-week gap between treatments. Patients who are on dimethyl fumarate for less than six months are 0.6 times less likely to be unstable than patients on dimethyl fumarate for longer than six months. In other words, patients on dimethyl fumarate for longer than six months are 1.7 times more likely to be unstable.

According to the researchers, an extension of this study will look at MRI changes and relapse rate after a patient has stopped natalizumab therapy and switched to dimethyl fumarate.

INDIANAPOLIS—A majority of patients remain stable when switching from natalizumab to dimethyl fumarate, according to data presented at the 2015 CMSC Annual Meeting. Factors such as sex, age, and duration of natalizumab treatment may predict the probability of a successful transition, reported lead author Faria S. Amjad, MD, of Georgetown University Hospital in Washington, DC, and research colleagues.

Natalizumab is a monoclonal antibody that prevents entry of leukocytes into the CNS. This mechanism of action has made it one of the most effective therapies against multiple sclerosis (MS). However, natalizumab’s use is limited by its risk of progressive multifocal leukoencephalopathy (PML). Moreover, switching from natalizumab to another therapeutic agent is made even more complex, as there is an increased risk of rebound inflammation. Dimethyl fumarate is an oral agent that offers a therapeutic alternative to patients stopping natalizumab. However, the safety and efficacy of this switch have not been studied.

To assess the stability of patients switched from natalizumab to dimethyl fumarate, Dr. Amjad and colleagues conducted a telephone survey and chart review for 66 patients with relapsing-remitting MS who had been switched from natalizumab to dimethyl fumarate. Factors analyzed included age, gender, duration on natalizumab, and duration on dimethyl fumarate.

A total of 66 patients were surveyed; 47 (71.22%) remained stable when switched to dimethyl fumarate, and 19 (28.78%) were found to be unstable on dimethyl fumarate. While the findings were not statistically significant, several trends were noted. Female patients were 2.9 times more likely to be unstable, compared with males. Patients younger than 60 were 1.8 times more likely to be unstable, compared with patients older than 60. Patients on natalizumab for less than two years were 2.4 times more likely to be unstable, compared with patients on natulizumab for more than two years. Patients who have an eight-week or less gap between natulizumab and dimethyl fumarate are just as likely to develop instability as patients with more than an eight-week gap between treatments. Patients who are on dimethyl fumarate for less than six months are 0.6 times less likely to be unstable than patients on dimethyl fumarate for longer than six months. In other words, patients on dimethyl fumarate for longer than six months are 1.7 times more likely to be unstable.

According to the researchers, an extension of this study will look at MRI changes and relapse rate after a patient has stopped natalizumab therapy and switched to dimethyl fumarate.

INDIANAPOLIS—Self-reported monitoring through an automated telehealth mechanism can provide a valid assessment of disease-modifying therapy (DMT) adherence among patients with multiple sclerosis (MS), according to study findings reported at the 2015 CMSC Annual Meeting. Further, utilizing an automated electronic system reduces the time spent making phone calls and researching pharmacy refill records by healthcare providers, according to Jill R. Settle and her research colleagues. Ms. Settle is affiliated with the MS Center of Excellence at the Veterans Affairs Medical Center in Washington, DC.

DMTs for MS have been available for more than 20 years; however, adherence to DMT regimens is often poor. The most common reason cited by patients is forgetting to take their medications on the specific day they are to be administered. To address the issue of non-adherence, Ms. Settle and colleagues sought to establish the feasibility of implementing a home telehealth program to support and monitor MS medication adherence without increasing healthcare provider burden.

The researchers addressed the assessment of poor adherence using a comprehensive Home Automated Telemanagement system for MS (MS HAT). MS HAT is a home-based Internet module that supports patient self-management, patient–provider communication, and patient education.

For approximately six months, 30 study participants were randomized to either MS HAT or treatment as usual. All participants stored their interferon β-1a syringes in a clear syringe container and maintained a paper calendar of medication adherence. Pharmacy refill rates were also collected from medical records. Participants in the MS HAT study arm received text or e-mail reminders to administer their medication.

There were no significant differences in demographic variables between the two groups. Likewise, overall adherence did not differ between the two groups. MS HAT alert rates were negatively correlated with syringe counts. As alerts decreased, syringes collected increased. Syringe count was positively related to change in Morisky score for interferon β-1a. As self-reported adherence improved, the number of syringes collected also increased. Pharmacy refills were directly related to calendar reports of taking the medication and syringe counts. As pharmacy refills increased, so did calendar reports and syringes collected.

The strong correlation between self-report and objective measures of adherence suggests that the MS HAT system is effective and cost-efficient.

INDIANAPOLIS—Self-reported monitoring through an automated telehealth mechanism can provide a valid assessment of disease-modifying therapy (DMT) adherence among patients with multiple sclerosis (MS), according to study findings reported at the 2015 CMSC Annual Meeting. Further, utilizing an automated electronic system reduces the time spent making phone calls and researching pharmacy refill records by healthcare providers, according to Jill R. Settle and her research colleagues. Ms. Settle is affiliated with the MS Center of Excellence at the Veterans Affairs Medical Center in Washington, DC.

DMTs for MS have been available for more than 20 years; however, adherence to DMT regimens is often poor. The most common reason cited by patients is forgetting to take their medications on the specific day they are to be administered. To address the issue of non-adherence, Ms. Settle and colleagues sought to establish the feasibility of implementing a home telehealth program to support and monitor MS medication adherence without increasing healthcare provider burden.

The researchers addressed the assessment of poor adherence using a comprehensive Home Automated Telemanagement system for MS (MS HAT). MS HAT is a home-based Internet module that supports patient self-management, patient–provider communication, and patient education.

For approximately six months, 30 study participants were randomized to either MS HAT or treatment as usual. All participants stored their interferon β-1a syringes in a clear syringe container and maintained a paper calendar of medication adherence. Pharmacy refill rates were also collected from medical records. Participants in the MS HAT study arm received text or e-mail reminders to administer their medication.

There were no significant differences in demographic variables between the two groups. Likewise, overall adherence did not differ between the two groups. MS HAT alert rates were negatively correlated with syringe counts. As alerts decreased, syringes collected increased. Syringe count was positively related to change in Morisky score for interferon β-1a. As self-reported adherence improved, the number of syringes collected also increased. Pharmacy refills were directly related to calendar reports of taking the medication and syringe counts. As pharmacy refills increased, so did calendar reports and syringes collected.

The strong correlation between self-report and objective measures of adherence suggests that the MS HAT system is effective and cost-efficient.

INDIANAPOLIS—Self-reported monitoring through an automated telehealth mechanism can provide a valid assessment of disease-modifying therapy (DMT) adherence among patients with multiple sclerosis (MS), according to study findings reported at the 2015 CMSC Annual Meeting. Further, utilizing an automated electronic system reduces the time spent making phone calls and researching pharmacy refill records by healthcare providers, according to Jill R. Settle and her research colleagues. Ms. Settle is affiliated with the MS Center of Excellence at the Veterans Affairs Medical Center in Washington, DC.

DMTs for MS have been available for more than 20 years; however, adherence to DMT regimens is often poor. The most common reason cited by patients is forgetting to take their medications on the specific day they are to be administered. To address the issue of non-adherence, Ms. Settle and colleagues sought to establish the feasibility of implementing a home telehealth program to support and monitor MS medication adherence without increasing healthcare provider burden.

The researchers addressed the assessment of poor adherence using a comprehensive Home Automated Telemanagement system for MS (MS HAT). MS HAT is a home-based Internet module that supports patient self-management, patient–provider communication, and patient education.

For approximately six months, 30 study participants were randomized to either MS HAT or treatment as usual. All participants stored their interferon β-1a syringes in a clear syringe container and maintained a paper calendar of medication adherence. Pharmacy refill rates were also collected from medical records. Participants in the MS HAT study arm received text or e-mail reminders to administer their medication.

There were no significant differences in demographic variables between the two groups. Likewise, overall adherence did not differ between the two groups. MS HAT alert rates were negatively correlated with syringe counts. As alerts decreased, syringes collected increased. Syringe count was positively related to change in Morisky score for interferon β-1a. As self-reported adherence improved, the number of syringes collected also increased. Pharmacy refills were directly related to calendar reports of taking the medication and syringe counts. As pharmacy refills increased, so did calendar reports and syringes collected.

The strong correlation between self-report and objective measures of adherence suggests that the MS HAT system is effective and cost-efficient.

INDIANAPOLIS—Although many women with multiple sclerosis (MS) are perimenopausal, the literature contains few data about effective ways to manage these women’s symptoms, according to research presented at the 2015 CMSC Annual Meeting. The topic could be considered to inhabit an “evidence-free zone,” but general recommendations are possible, according to Riley Bove, MD, Instructor at Harvard Medical School in Boston.

During menopause, women may have vasomotor symptoms such as hot flashes, vascular instability, and rapid heartbeat. For patients with MS, these symptoms may disturb sleep, contribute to fatigue, and affect mood. Vasomotor symptoms also may cause exacerbations. Hormone replacement therapy is the most effective treatment for vasomotor symptoms. In the Women’s Health Initiative Memory Study, however, hormone replacement therapy initiated in women age 65 or older was associated with an increased risk of dementia and cognitive decline. This association should be examined in longitudinal placebo-controlled trials, said Dr. Bove.

Bladder symptoms and sleep apnea are more common during menopause and can cause frequent awakenings, which lead to mood disturbances (eg, depression or anxiety) and relational problems in patients with MS. To improve sleep, neurologists should advise their patients about good sleep hygiene. Patients should stay in bed for only a certain amount of time, use their bed for sleep or intimacy only, schedule regular wake times, and moderate caffeine intake, among other behaviors.

Fatigue is common in MS, and its severity and frequency tend to increase during menopause. Neurologists should rule out additional contributors to fatigue, such as thyroid disease. Patients should be advised to arrange their daily schedule so that work routines are spaced out. They should take intermittent rest breaks and try to concentrate their activity in the morning when it is cooler. Relaxation and meditation practices can reduce stress and decrease fatigue. Drugs such as modafinil and amantadine can promote wakefulness, and methylphenidate can be used as a stimulant.

Pain tolerance may decrease during menopause, and patients with MS often have cervical and lumbar spondylosis, joint immobility, spasticity, and deconditioning. Baclofen, diazepam, dantrolene, and tizanidine may be effective for pain resulting from spasticity. Phenytoin, carbamazepine, and tricyclic antidepressants can alleviate neuropathic pain and paresthesias. Neurologists also might recommend weight loss or exercise or refer a patient to a pain center for an integrated approach to the condition.

Mood disorders are common among patients with MS, and mood fluctuations may accompany menopause. In response to this problem, a neurologist may recommend psychotherapy to help optimize the patient’s coping abilities. Spousal and interpersonal support also are important for the patient. Antidepressants such as fluoxetine, sertraline, escitalopram, and citalopram can be effective if drug therapy is warranted. Support groups also may help stabilize the patient’s mood.

—Erik Greb

INDIANAPOLIS—Although many women with multiple sclerosis (MS) are perimenopausal, the literature contains few data about effective ways to manage these women’s symptoms, according to research presented at the 2015 CMSC Annual Meeting. The topic could be considered to inhabit an “evidence-free zone,” but general recommendations are possible, according to Riley Bove, MD, Instructor at Harvard Medical School in Boston.

During menopause, women may have vasomotor symptoms such as hot flashes, vascular instability, and rapid heartbeat. For patients with MS, these symptoms may disturb sleep, contribute to fatigue, and affect mood. Vasomotor symptoms also may cause exacerbations. Hormone replacement therapy is the most effective treatment for vasomotor symptoms. In the Women’s Health Initiative Memory Study, however, hormone replacement therapy initiated in women age 65 or older was associated with an increased risk of dementia and cognitive decline. This association should be examined in longitudinal placebo-controlled trials, said Dr. Bove.

Bladder symptoms and sleep apnea are more common during menopause and can cause frequent awakenings, which lead to mood disturbances (eg, depression or anxiety) and relational problems in patients with MS. To improve sleep, neurologists should advise their patients about good sleep hygiene. Patients should stay in bed for only a certain amount of time, use their bed for sleep or intimacy only, schedule regular wake times, and moderate caffeine intake, among other behaviors.

Fatigue is common in MS, and its severity and frequency tend to increase during menopause. Neurologists should rule out additional contributors to fatigue, such as thyroid disease. Patients should be advised to arrange their daily schedule so that work routines are spaced out. They should take intermittent rest breaks and try to concentrate their activity in the morning when it is cooler. Relaxation and meditation practices can reduce stress and decrease fatigue. Drugs such as modafinil and amantadine can promote wakefulness, and methylphenidate can be used as a stimulant.

Pain tolerance may decrease during menopause, and patients with MS often have cervical and lumbar spondylosis, joint immobility, spasticity, and deconditioning. Baclofen, diazepam, dantrolene, and tizanidine may be effective for pain resulting from spasticity. Phenytoin, carbamazepine, and tricyclic antidepressants can alleviate neuropathic pain and paresthesias. Neurologists also might recommend weight loss or exercise or refer a patient to a pain center for an integrated approach to the condition.

Mood disorders are common among patients with MS, and mood fluctuations may accompany menopause. In response to this problem, a neurologist may recommend psychotherapy to help optimize the patient’s coping abilities. Spousal and interpersonal support also are important for the patient. Antidepressants such as fluoxetine, sertraline, escitalopram, and citalopram can be effective if drug therapy is warranted. Support groups also may help stabilize the patient’s mood.

—Erik Greb

INDIANAPOLIS—Although many women with multiple sclerosis (MS) are perimenopausal, the literature contains few data about effective ways to manage these women’s symptoms, according to research presented at the 2015 CMSC Annual Meeting. The topic could be considered to inhabit an “evidence-free zone,” but general recommendations are possible, according to Riley Bove, MD, Instructor at Harvard Medical School in Boston.

During menopause, women may have vasomotor symptoms such as hot flashes, vascular instability, and rapid heartbeat. For patients with MS, these symptoms may disturb sleep, contribute to fatigue, and affect mood. Vasomotor symptoms also may cause exacerbations. Hormone replacement therapy is the most effective treatment for vasomotor symptoms. In the Women’s Health Initiative Memory Study, however, hormone replacement therapy initiated in women age 65 or older was associated with an increased risk of dementia and cognitive decline. This association should be examined in longitudinal placebo-controlled trials, said Dr. Bove.

Bladder symptoms and sleep apnea are more common during menopause and can cause frequent awakenings, which lead to mood disturbances (eg, depression or anxiety) and relational problems in patients with MS. To improve sleep, neurologists should advise their patients about good sleep hygiene. Patients should stay in bed for only a certain amount of time, use their bed for sleep or intimacy only, schedule regular wake times, and moderate caffeine intake, among other behaviors.

Fatigue is common in MS, and its severity and frequency tend to increase during menopause. Neurologists should rule out additional contributors to fatigue, such as thyroid disease. Patients should be advised to arrange their daily schedule so that work routines are spaced out. They should take intermittent rest breaks and try to concentrate their activity in the morning when it is cooler. Relaxation and meditation practices can reduce stress and decrease fatigue. Drugs such as modafinil and amantadine can promote wakefulness, and methylphenidate can be used as a stimulant.

Pain tolerance may decrease during menopause, and patients with MS often have cervical and lumbar spondylosis, joint immobility, spasticity, and deconditioning. Baclofen, diazepam, dantrolene, and tizanidine may be effective for pain resulting from spasticity. Phenytoin, carbamazepine, and tricyclic antidepressants can alleviate neuropathic pain and paresthesias. Neurologists also might recommend weight loss or exercise or refer a patient to a pain center for an integrated approach to the condition.

Mood disorders are common among patients with MS, and mood fluctuations may accompany menopause. In response to this problem, a neurologist may recommend psychotherapy to help optimize the patient’s coping abilities. Spousal and interpersonal support also are important for the patient. Antidepressants such as fluoxetine, sertraline, escitalopram, and citalopram can be effective if drug therapy is warranted. Support groups also may help stabilize the patient’s mood.

—Erik Greb

INDIANAPOLIS—Early detection of progressive multifocal leukoencephalopathy (PML) may improve outcomes, according to an update presented at the 2015 CMSC Annual Meeting. When PML results from reversible immunosuppression, as in patients with multiple sclerosis (MS) who are receiving monoclonal antibodies, the immediate cessation of the offending agent is recommended.

The pathogenesis of PML is not well understood, but the initial infection may be oropharyngeal or respiratory, said Joseph R. Berger, MD, Professor of Neurology at the Hospital of the University of Pennsylvania in Philadelphia. The infection spreads to sites of latency and may be re-expressed with circulation in B cells before entering the CNS.

As of March 3, 2015, 541 cases of PML have been reported in patients receiving natalizumab. Of these patients, 538 had MS. The patients’ mean duration of treatment with natalizumab was 42 months. Approximately 8% of patients were a-symptomatic at the time of diagnosis. Data have suggested that exposure to John Cunningham virus (JCV), prior immunosuppressive therapy, and longer treatment duration are risk factors for PML.

Since 2013, New England Journal of Medicine has published three case reports of PML in patients receiving dimethyl fumarate. In one of the cases, the drug had been manufactured by a compounding pharmacy. The literature also contains two cases of PML in patients receiving fingolimod.

To date, 160 cases of PML have been reported in patients receiving rituximab, but none of these cases occurred in patients with MS. Almost all cases of PML related to rituximab were in patients with chronic lymphocytic leukemia or other lymphoproliferative diseases. The drug has a black box warning, but the risk of PML for patients receiving this therapy probably is “vanishingly low,” said Dr. Berger.

A total of 57 patients receiving alemtuzumab have developed PML. Fifty-five of these individuals had chronic lymphocytic leukemia, and two developed PML after a lung transplant. Alemtuzumab depletes B cells, which recover in 27 months, and T cells, which recover in 61 months.

Diagnosis of PML depends on neuropathologic demonstration of demyelination, bizarre astrocytes, and enlarged oligodendroglial nuclei. The presence of JCV also must be established by polymerase chain reaction. A two-step Enzyme Linked Immunosorbent Assay can detect JCV antibodies, but it has a significant risk of false seronegativity, said Dr. Berger.

On CT imaging, PML manifests as hypodense lesions and, in less than 10% of cases, as contrast enhancement. PML is visible as hypointense lesions on T1 MRI and as increased signal on T2 MRI and FLAIR. PML is not associated with mass effect on MRI and often affects parieto-occipital and frontal lobes. The condition may affect atypical locations such as the cerebellum, brainstem, basal ganglia, or temporal lobe.

—Erik Greb

INDIANAPOLIS—Early detection of progressive multifocal leukoencephalopathy (PML) may improve outcomes, according to an update presented at the 2015 CMSC Annual Meeting. When PML results from reversible immunosuppression, as in patients with multiple sclerosis (MS) who are receiving monoclonal antibodies, the immediate cessation of the offending agent is recommended.

The pathogenesis of PML is not well understood, but the initial infection may be oropharyngeal or respiratory, said Joseph R. Berger, MD, Professor of Neurology at the Hospital of the University of Pennsylvania in Philadelphia. The infection spreads to sites of latency and may be re-expressed with circulation in B cells before entering the CNS.

As of March 3, 2015, 541 cases of PML have been reported in patients receiving natalizumab. Of these patients, 538 had MS. The patients’ mean duration of treatment with natalizumab was 42 months. Approximately 8% of patients were a-symptomatic at the time of diagnosis. Data have suggested that exposure to John Cunningham virus (JCV), prior immunosuppressive therapy, and longer treatment duration are risk factors for PML.

Since 2013, New England Journal of Medicine has published three case reports of PML in patients receiving dimethyl fumarate. In one of the cases, the drug had been manufactured by a compounding pharmacy. The literature also contains two cases of PML in patients receiving fingolimod.

To date, 160 cases of PML have been reported in patients receiving rituximab, but none of these cases occurred in patients with MS. Almost all cases of PML related to rituximab were in patients with chronic lymphocytic leukemia or other lymphoproliferative diseases. The drug has a black box warning, but the risk of PML for patients receiving this therapy probably is “vanishingly low,” said Dr. Berger.

A total of 57 patients receiving alemtuzumab have developed PML. Fifty-five of these individuals had chronic lymphocytic leukemia, and two developed PML after a lung transplant. Alemtuzumab depletes B cells, which recover in 27 months, and T cells, which recover in 61 months.

Diagnosis of PML depends on neuropathologic demonstration of demyelination, bizarre astrocytes, and enlarged oligodendroglial nuclei. The presence of JCV also must be established by polymerase chain reaction. A two-step Enzyme Linked Immunosorbent Assay can detect JCV antibodies, but it has a significant risk of false seronegativity, said Dr. Berger.

On CT imaging, PML manifests as hypodense lesions and, in less than 10% of cases, as contrast enhancement. PML is visible as hypointense lesions on T1 MRI and as increased signal on T2 MRI and FLAIR. PML is not associated with mass effect on MRI and often affects parieto-occipital and frontal lobes. The condition may affect atypical locations such as the cerebellum, brainstem, basal ganglia, or temporal lobe.

—Erik Greb

INDIANAPOLIS—Early detection of progressive multifocal leukoencephalopathy (PML) may improve outcomes, according to an update presented at the 2015 CMSC Annual Meeting. When PML results from reversible immunosuppression, as in patients with multiple sclerosis (MS) who are receiving monoclonal antibodies, the immediate cessation of the offending agent is recommended.

The pathogenesis of PML is not well understood, but the initial infection may be oropharyngeal or respiratory, said Joseph R. Berger, MD, Professor of Neurology at the Hospital of the University of Pennsylvania in Philadelphia. The infection spreads to sites of latency and may be re-expressed with circulation in B cells before entering the CNS.

As of March 3, 2015, 541 cases of PML have been reported in patients receiving natalizumab. Of these patients, 538 had MS. The patients’ mean duration of treatment with natalizumab was 42 months. Approximately 8% of patients were a-symptomatic at the time of diagnosis. Data have suggested that exposure to John Cunningham virus (JCV), prior immunosuppressive therapy, and longer treatment duration are risk factors for PML.

Since 2013, New England Journal of Medicine has published three case reports of PML in patients receiving dimethyl fumarate. In one of the cases, the drug had been manufactured by a compounding pharmacy. The literature also contains two cases of PML in patients receiving fingolimod.

To date, 160 cases of PML have been reported in patients receiving rituximab, but none of these cases occurred in patients with MS. Almost all cases of PML related to rituximab were in patients with chronic lymphocytic leukemia or other lymphoproliferative diseases. The drug has a black box warning, but the risk of PML for patients receiving this therapy probably is “vanishingly low,” said Dr. Berger.

A total of 57 patients receiving alemtuzumab have developed PML. Fifty-five of these individuals had chronic lymphocytic leukemia, and two developed PML after a lung transplant. Alemtuzumab depletes B cells, which recover in 27 months, and T cells, which recover in 61 months.

Diagnosis of PML depends on neuropathologic demonstration of demyelination, bizarre astrocytes, and enlarged oligodendroglial nuclei. The presence of JCV also must be established by polymerase chain reaction. A two-step Enzyme Linked Immunosorbent Assay can detect JCV antibodies, but it has a significant risk of false seronegativity, said Dr. Berger.

On CT imaging, PML manifests as hypodense lesions and, in less than 10% of cases, as contrast enhancement. PML is visible as hypointense lesions on T1 MRI and as increased signal on T2 MRI and FLAIR. PML is not associated with mass effect on MRI and often affects parieto-occipital and frontal lobes. The condition may affect atypical locations such as the cerebellum, brainstem, basal ganglia, or temporal lobe.

—Erik Greb

INDIANAPOLIS—Smoked cannabis may compromise cognitive function in patients with multiple sclerosis (MS), according to an overview presented at the 2015 Consortium of MS Centers Annual Meeting. Evidence does not support the hypothesis that cannabis affects mood or causes anxiety or psychosis, however. Clinicians should weigh the potentially harmful effects of cannabis on cognition against the drug’s possible benefits for pain, spasticity, and urinary problems.

Between 40% and 70% of people with MS have cognitive dysfunction, which may include deficits in information processing speed, working memory, visuospatial memory, or executive function, said Anthony Feinstein, MD, PhD, Professor of Psychiatry at the University of Toronto. Approximately 40% of patients with MS have used cannabis, and Dr. Feinstein studies the drug’s effects on cognition among patients with MS.

In 2008, he and his colleagues interviewed 140 consecutive patients with MS with the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) Axis I disorders. The researchers assessed cognition using the Neuropsychological Battery for MS, supplemented with the Symbol Digit Modalities Test (SDMT). When the investigators compared 10 current cannabis users with 40 matched controls with MS, they found that cannabis users had a slower mean performance time on the SDMT and a different pattern of response, compared with the matched controls.

In 2011, Dr. Feinstein and colleagues compared 25 patients with MS who smoked cannabis with 25 patients with MS who did not smoke cannabis. Participants underwent the Minimal Assessment of Cognitive Function in MS battery of neuropsychologic tests, the Hospital Anxiety and Depression Scale (HADS), and the Structured Clinical Interview for the DSM-IV Axis I Disorders. The two patient groups were matched for demographic and disease variables. Cannabis users were more likely to be unemployed than nonusers and also had more cognitive deficits, including in visuospatial perception, executive function, and information processing speed, compared with nonusers. The researchers found no differences between groups in depression or anxiety, however.

Finally, in 2014, Dr. Feinstein and colleagues performed a cross-sectional study of 20 patients with MS who smoked cannabis and 19 patients with MS who did not. Participants underwent fMRI while completing the N-Back test of working memory. Spatial memory and Paced Auditory Serial Addition Test scores were lower among patients who smoked cannabis. These patients also had slowed responses and more errors on the N-Back test, compared with cannabis nonusers. During this test, cannabis users also had increased activation in parietal and anterior cingulate regions implicated in working memory, compared with nonusers.

—Erik Greb

INDIANAPOLIS—Smoked cannabis may compromise cognitive function in patients with multiple sclerosis (MS), according to an overview presented at the 2015 Consortium of MS Centers Annual Meeting. Evidence does not support the hypothesis that cannabis affects mood or causes anxiety or psychosis, however. Clinicians should weigh the potentially harmful effects of cannabis on cognition against the drug’s possible benefits for pain, spasticity, and urinary problems.

Between 40% and 70% of people with MS have cognitive dysfunction, which may include deficits in information processing speed, working memory, visuospatial memory, or executive function, said Anthony Feinstein, MD, PhD, Professor of Psychiatry at the University of Toronto. Approximately 40% of patients with MS have used cannabis, and Dr. Feinstein studies the drug’s effects on cognition among patients with MS.

In 2008, he and his colleagues interviewed 140 consecutive patients with MS with the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) Axis I disorders. The researchers assessed cognition using the Neuropsychological Battery for MS, supplemented with the Symbol Digit Modalities Test (SDMT). When the investigators compared 10 current cannabis users with 40 matched controls with MS, they found that cannabis users had a slower mean performance time on the SDMT and a different pattern of response, compared with the matched controls.

In 2011, Dr. Feinstein and colleagues compared 25 patients with MS who smoked cannabis with 25 patients with MS who did not smoke cannabis. Participants underwent the Minimal Assessment of Cognitive Function in MS battery of neuropsychologic tests, the Hospital Anxiety and Depression Scale (HADS), and the Structured Clinical Interview for the DSM-IV Axis I Disorders. The two patient groups were matched for demographic and disease variables. Cannabis users were more likely to be unemployed than nonusers and also had more cognitive deficits, including in visuospatial perception, executive function, and information processing speed, compared with nonusers. The researchers found no differences between groups in depression or anxiety, however.

Finally, in 2014, Dr. Feinstein and colleagues performed a cross-sectional study of 20 patients with MS who smoked cannabis and 19 patients with MS who did not. Participants underwent fMRI while completing the N-Back test of working memory. Spatial memory and Paced Auditory Serial Addition Test scores were lower among patients who smoked cannabis. These patients also had slowed responses and more errors on the N-Back test, compared with cannabis nonusers. During this test, cannabis users also had increased activation in parietal and anterior cingulate regions implicated in working memory, compared with nonusers.

—Erik Greb

INDIANAPOLIS—Smoked cannabis may compromise cognitive function in patients with multiple sclerosis (MS), according to an overview presented at the 2015 Consortium of MS Centers Annual Meeting. Evidence does not support the hypothesis that cannabis affects mood or causes anxiety or psychosis, however. Clinicians should weigh the potentially harmful effects of cannabis on cognition against the drug’s possible benefits for pain, spasticity, and urinary problems.

Between 40% and 70% of people with MS have cognitive dysfunction, which may include deficits in information processing speed, working memory, visuospatial memory, or executive function, said Anthony Feinstein, MD, PhD, Professor of Psychiatry at the University of Toronto. Approximately 40% of patients with MS have used cannabis, and Dr. Feinstein studies the drug’s effects on cognition among patients with MS.

In 2008, he and his colleagues interviewed 140 consecutive patients with MS with the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) Axis I disorders. The researchers assessed cognition using the Neuropsychological Battery for MS, supplemented with the Symbol Digit Modalities Test (SDMT). When the investigators compared 10 current cannabis users with 40 matched controls with MS, they found that cannabis users had a slower mean performance time on the SDMT and a different pattern of response, compared with the matched controls.

In 2011, Dr. Feinstein and colleagues compared 25 patients with MS who smoked cannabis with 25 patients with MS who did not smoke cannabis. Participants underwent the Minimal Assessment of Cognitive Function in MS battery of neuropsychologic tests, the Hospital Anxiety and Depression Scale (HADS), and the Structured Clinical Interview for the DSM-IV Axis I Disorders. The two patient groups were matched for demographic and disease variables. Cannabis users were more likely to be unemployed than nonusers and also had more cognitive deficits, including in visuospatial perception, executive function, and information processing speed, compared with nonusers. The researchers found no differences between groups in depression or anxiety, however.

Finally, in 2014, Dr. Feinstein and colleagues performed a cross-sectional study of 20 patients with MS who smoked cannabis and 19 patients with MS who did not. Participants underwent fMRI while completing the N-Back test of working memory. Spatial memory and Paced Auditory Serial Addition Test scores were lower among patients who smoked cannabis. These patients also had slowed responses and more errors on the N-Back test, compared with cannabis nonusers. During this test, cannabis users also had increased activation in parietal and anterior cingulate regions implicated in working memory, compared with nonusers.

—Erik Greb

INDIANAPOLIS—A standardized MRI is important for the diagnosis and follow-up of patients with multiple sclerosis (MS). However, acquisition and interpretation of MRI scans may be complicated due to differences in pulse sequence (eg, FLAIR vs PD/T2), the use of contiguous and thinner (eg, 3 mm vs 5 mm) slices, as well as different patient positioning. Therefore, the Consortium of Multiple Sclerosis Centers (CMSC) convened a task force to develop and periodically revise indications and guidelines for a standardized MRI protocol in the diagnosis and follow-up of patients with MS. The panel’s most recent recommendations were presented at the 2015 CMSC Annual Meeting and will be published in an upcoming issue of American Journal of Neuroradiology.

Lead author Anthony Traboulsee, MD, Associate Professor at the University of British Columbia in Vancouver, and colleagues reported that a standardized brain MRI protocol with gadolinium is recommended for the diagnosis of MS. A spinal cord MRI is additionally recommended if the brain MRI is nondiagnostic or if the presenting symptoms are at the level of the spinal cord. A follow-up brain MRI with gadolinium is recommended to demonstrate dissemination in time and ongoing clinically silent disease activity while on treatment, to evaluate unexpected clinical worsening, to re-assess the original diagnosis, and as a new baseline prior to starting or modifying therapy. A routine brain MRI should be considered every six months to two years for all patients with relapsing MS. The standardized brain MRI protocol includes 3D T1-weighted, 3D T2-FLAIR (fluid-attenuated inversion recovery), 3D T2-weighted, post single-dose gadolinium-enhanced T1-weighted, and a diffusion-weighted sequence.

According to the 2015 Revised CMSC MRI Protocol, a simplified progressive multifocal leukoencephalopathy (PML) surveillance protocol includes FLAIR and diffusion-weighted imaging sequences only.

The spinal cord MRI protocol includes sagittal T1-weighted and proton density, short-time inversion recovery (STIR) or phase-sensitive inversion recovery (PSIR), axial T2- or T2*-weighted through suspicious lesions, and, in some cases, post-contrast gadolinium-enhanced T1-weighted imaging.

The task force’s revised guideline specifies that the clinical question being addressed should be provided in the requisition for the MRI. The radiology report should be descriptive with results referenced to previous studies. MRI studies should be permanently retained and available.

The 2015 revision incorporates new information and practice recommendations, and modification as modern imaging techniques (eg, 3D) have become more robust and available.

Key changes to the MRI protocol since the last revision in 2006 include an emphasis on 3D sequences for brain MRI, a PML-specific monitoring protocol, and an optional orbit MRI protocol for severe optic neuritis.

Key changes to the clinical guidelines since the 2006 revision include more specific guidance on timing of brain MRI for patients on disease-modifying therapy, timing of brain MRI for PML surveillance, updated evidence on the value of MRI changes in determining treatment effectiveness, and inclusion of radiologically isolated syndrome.

INDIANAPOLIS—A standardized MRI is important for the diagnosis and follow-up of patients with multiple sclerosis (MS). However, acquisition and interpretation of MRI scans may be complicated due to differences in pulse sequence (eg, FLAIR vs PD/T2), the use of contiguous and thinner (eg, 3 mm vs 5 mm) slices, as well as different patient positioning. Therefore, the Consortium of Multiple Sclerosis Centers (CMSC) convened a task force to develop and periodically revise indications and guidelines for a standardized MRI protocol in the diagnosis and follow-up of patients with MS. The panel’s most recent recommendations were presented at the 2015 CMSC Annual Meeting and will be published in an upcoming issue of American Journal of Neuroradiology.

Lead author Anthony Traboulsee, MD, Associate Professor at the University of British Columbia in Vancouver, and colleagues reported that a standardized brain MRI protocol with gadolinium is recommended for the diagnosis of MS. A spinal cord MRI is additionally recommended if the brain MRI is nondiagnostic or if the presenting symptoms are at the level of the spinal cord. A follow-up brain MRI with gadolinium is recommended to demonstrate dissemination in time and ongoing clinically silent disease activity while on treatment, to evaluate unexpected clinical worsening, to re-assess the original diagnosis, and as a new baseline prior to starting or modifying therapy. A routine brain MRI should be considered every six months to two years for all patients with relapsing MS. The standardized brain MRI protocol includes 3D T1-weighted, 3D T2-FLAIR (fluid-attenuated inversion recovery), 3D T2-weighted, post single-dose gadolinium-enhanced T1-weighted, and a diffusion-weighted sequence.

According to the 2015 Revised CMSC MRI Protocol, a simplified progressive multifocal leukoencephalopathy (PML) surveillance protocol includes FLAIR and diffusion-weighted imaging sequences only.

The spinal cord MRI protocol includes sagittal T1-weighted and proton density, short-time inversion recovery (STIR) or phase-sensitive inversion recovery (PSIR), axial T2- or T2*-weighted through suspicious lesions, and, in some cases, post-contrast gadolinium-enhanced T1-weighted imaging.

The task force’s revised guideline specifies that the clinical question being addressed should be provided in the requisition for the MRI. The radiology report should be descriptive with results referenced to previous studies. MRI studies should be permanently retained and available.

The 2015 revision incorporates new information and practice recommendations, and modification as modern imaging techniques (eg, 3D) have become more robust and available.

Key changes to the MRI protocol since the last revision in 2006 include an emphasis on 3D sequences for brain MRI, a PML-specific monitoring protocol, and an optional orbit MRI protocol for severe optic neuritis.

Key changes to the clinical guidelines since the 2006 revision include more specific guidance on timing of brain MRI for patients on disease-modifying therapy, timing of brain MRI for PML surveillance, updated evidence on the value of MRI changes in determining treatment effectiveness, and inclusion of radiologically isolated syndrome.

INDIANAPOLIS—A standardized MRI is important for the diagnosis and follow-up of patients with multiple sclerosis (MS). However, acquisition and interpretation of MRI scans may be complicated due to differences in pulse sequence (eg, FLAIR vs PD/T2), the use of contiguous and thinner (eg, 3 mm vs 5 mm) slices, as well as different patient positioning. Therefore, the Consortium of Multiple Sclerosis Centers (CMSC) convened a task force to develop and periodically revise indications and guidelines for a standardized MRI protocol in the diagnosis and follow-up of patients with MS. The panel’s most recent recommendations were presented at the 2015 CMSC Annual Meeting and will be published in an upcoming issue of American Journal of Neuroradiology.

Lead author Anthony Traboulsee, MD, Associate Professor at the University of British Columbia in Vancouver, and colleagues reported that a standardized brain MRI protocol with gadolinium is recommended for the diagnosis of MS. A spinal cord MRI is additionally recommended if the brain MRI is nondiagnostic or if the presenting symptoms are at the level of the spinal cord. A follow-up brain MRI with gadolinium is recommended to demonstrate dissemination in time and ongoing clinically silent disease activity while on treatment, to evaluate unexpected clinical worsening, to re-assess the original diagnosis, and as a new baseline prior to starting or modifying therapy. A routine brain MRI should be considered every six months to two years for all patients with relapsing MS. The standardized brain MRI protocol includes 3D T1-weighted, 3D T2-FLAIR (fluid-attenuated inversion recovery), 3D T2-weighted, post single-dose gadolinium-enhanced T1-weighted, and a diffusion-weighted sequence.

According to the 2015 Revised CMSC MRI Protocol, a simplified progressive multifocal leukoencephalopathy (PML) surveillance protocol includes FLAIR and diffusion-weighted imaging sequences only.

The spinal cord MRI protocol includes sagittal T1-weighted and proton density, short-time inversion recovery (STIR) or phase-sensitive inversion recovery (PSIR), axial T2- or T2*-weighted through suspicious lesions, and, in some cases, post-contrast gadolinium-enhanced T1-weighted imaging.

The task force’s revised guideline specifies that the clinical question being addressed should be provided in the requisition for the MRI. The radiology report should be descriptive with results referenced to previous studies. MRI studies should be permanently retained and available.

The 2015 revision incorporates new information and practice recommendations, and modification as modern imaging techniques (eg, 3D) have become more robust and available.

Key changes to the MRI protocol since the last revision in 2006 include an emphasis on 3D sequences for brain MRI, a PML-specific monitoring protocol, and an optional orbit MRI protocol for severe optic neuritis.

Key changes to the clinical guidelines since the 2006 revision include more specific guidance on timing of brain MRI for patients on disease-modifying therapy, timing of brain MRI for PML surveillance, updated evidence on the value of MRI changes in determining treatment effectiveness, and inclusion of radiologically isolated syndrome.

INDIANAPOLIS—For patients with multiple sclerosis (MS), making treatment decisions is a complex undertaking. The decisions involve clinical factors such as symptom severity, level of disability, and disease duration. Physician recommendations play a major role, but insurance coverage and financial situation also may be factors. Important changes to insurance coverage in the last few years may have required some patients to change their disease-modifying therapies (DMTs) for financial rather than clinical reasons.

To examine this issue, Stacey S. Cofield, PhD, a biostatistician at the University of Alabama at Birmingham, and her colleagues utilized patient-reported data from the NARCOMS registry to describe the insurance status of patient participants and how insurance and financial situation affect their DMT choices. Their findings were reported at the 2015 CMSC Annual Meeting.

The NARCOMS Fall 2014 Update survey included the following questions about health insurance and DMT choices related to insurance: current health insurance (Yes/No), health insurance for the prior six months (Yes/No), comparison of current health insurance to 12 months prior (better, worse, unchanged), and how insurance/financial situation has influenced treatment of MS. Dr. Cofield and colleagues reported on only registry participants who completed the survey online. Data entry for paper forms collected during the Fall 2014 Update is ongoing.

Of the 5,106 participants who completed the survey online, 4,507 (96.9%) completed the health insurance questions, 78.8% were female (mean age 56.7), and 62.1% had relapsing-remitting MS. Nearly all (99.5%) participants had health insurance. Likewise, nearly all (98.6%) had insurance for the prior six months, with 68.6% reporting insurance coverage had not changed in the prior year, while 23.0% reported worse coverage compared to 12 months ago. Coverage did not differ by gender or MS type, but more females reported their insurance coverage to be worse compared to 12 months ago (23.9% vs 19.7%). More respondents with progressive MS reported no change in coverage compared to those with relapsing-remitting MS (73.3% vs 66.8%). When asked about influence of insurance or financial situation on DMT choice, 30.0% reported not taking DMT by choice or physician recommendation, 15.9% took their DMT of choice with full coverage, 46.6% with a co-pay, 19.1% with free/discounted drug program, 3.6% were able to switch DMTs with insurance approval, 1.3% would like to switch but could not due to lack of insurance approval/coverage, while 2.4% had to stop/change/skip DMTs due to higher co-pays, and 1.6% did not take DMTs because they did not have insurance or insurance denied the DMT.

Dr. Cofield reported that most participants in the NARCOMS MS patient registry did not perceive major impacts from their insurance or financial situation with regard to DMT choice. Many patients, however, rely on assistance for DMT coverage or are not able to take a DMT as directed or at all due to their current insurance or financial situation.

INDIANAPOLIS—For patients with multiple sclerosis (MS), making treatment decisions is a complex undertaking. The decisions involve clinical factors such as symptom severity, level of disability, and disease duration. Physician recommendations play a major role, but insurance coverage and financial situation also may be factors. Important changes to insurance coverage in the last few years may have required some patients to change their disease-modifying therapies (DMTs) for financial rather than clinical reasons.

To examine this issue, Stacey S. Cofield, PhD, a biostatistician at the University of Alabama at Birmingham, and her colleagues utilized patient-reported data from the NARCOMS registry to describe the insurance status of patient participants and how insurance and financial situation affect their DMT choices. Their findings were reported at the 2015 CMSC Annual Meeting.

The NARCOMS Fall 2014 Update survey included the following questions about health insurance and DMT choices related to insurance: current health insurance (Yes/No), health insurance for the prior six months (Yes/No), comparison of current health insurance to 12 months prior (better, worse, unchanged), and how insurance/financial situation has influenced treatment of MS. Dr. Cofield and colleagues reported on only registry participants who completed the survey online. Data entry for paper forms collected during the Fall 2014 Update is ongoing.

Of the 5,106 participants who completed the survey online, 4,507 (96.9%) completed the health insurance questions, 78.8% were female (mean age 56.7), and 62.1% had relapsing-remitting MS. Nearly all (99.5%) participants had health insurance. Likewise, nearly all (98.6%) had insurance for the prior six months, with 68.6% reporting insurance coverage had not changed in the prior year, while 23.0% reported worse coverage compared to 12 months ago. Coverage did not differ by gender or MS type, but more females reported their insurance coverage to be worse compared to 12 months ago (23.9% vs 19.7%). More respondents with progressive MS reported no change in coverage compared to those with relapsing-remitting MS (73.3% vs 66.8%). When asked about influence of insurance or financial situation on DMT choice, 30.0% reported not taking DMT by choice or physician recommendation, 15.9% took their DMT of choice with full coverage, 46.6% with a co-pay, 19.1% with free/discounted drug program, 3.6% were able to switch DMTs with insurance approval, 1.3% would like to switch but could not due to lack of insurance approval/coverage, while 2.4% had to stop/change/skip DMTs due to higher co-pays, and 1.6% did not take DMTs because they did not have insurance or insurance denied the DMT.

Dr. Cofield reported that most participants in the NARCOMS MS patient registry did not perceive major impacts from their insurance or financial situation with regard to DMT choice. Many patients, however, rely on assistance for DMT coverage or are not able to take a DMT as directed or at all due to their current insurance or financial situation.

INDIANAPOLIS—For patients with multiple sclerosis (MS), making treatment decisions is a complex undertaking. The decisions involve clinical factors such as symptom severity, level of disability, and disease duration. Physician recommendations play a major role, but insurance coverage and financial situation also may be factors. Important changes to insurance coverage in the last few years may have required some patients to change their disease-modifying therapies (DMTs) for financial rather than clinical reasons.

To examine this issue, Stacey S. Cofield, PhD, a biostatistician at the University of Alabama at Birmingham, and her colleagues utilized patient-reported data from the NARCOMS registry to describe the insurance status of patient participants and how insurance and financial situation affect their DMT choices. Their findings were reported at the 2015 CMSC Annual Meeting.

The NARCOMS Fall 2014 Update survey included the following questions about health insurance and DMT choices related to insurance: current health insurance (Yes/No), health insurance for the prior six months (Yes/No), comparison of current health insurance to 12 months prior (better, worse, unchanged), and how insurance/financial situation has influenced treatment of MS. Dr. Cofield and colleagues reported on only registry participants who completed the survey online. Data entry for paper forms collected during the Fall 2014 Update is ongoing.

Of the 5,106 participants who completed the survey online, 4,507 (96.9%) completed the health insurance questions, 78.8% were female (mean age 56.7), and 62.1% had relapsing-remitting MS. Nearly all (99.5%) participants had health insurance. Likewise, nearly all (98.6%) had insurance for the prior six months, with 68.6% reporting insurance coverage had not changed in the prior year, while 23.0% reported worse coverage compared to 12 months ago. Coverage did not differ by gender or MS type, but more females reported their insurance coverage to be worse compared to 12 months ago (23.9% vs 19.7%). More respondents with progressive MS reported no change in coverage compared to those with relapsing-remitting MS (73.3% vs 66.8%). When asked about influence of insurance or financial situation on DMT choice, 30.0% reported not taking DMT by choice or physician recommendation, 15.9% took their DMT of choice with full coverage, 46.6% with a co-pay, 19.1% with free/discounted drug program, 3.6% were able to switch DMTs with insurance approval, 1.3% would like to switch but could not due to lack of insurance approval/coverage, while 2.4% had to stop/change/skip DMTs due to higher co-pays, and 1.6% did not take DMTs because they did not have insurance or insurance denied the DMT.

Dr. Cofield reported that most participants in the NARCOMS MS patient registry did not perceive major impacts from their insurance or financial situation with regard to DMT choice. Many patients, however, rely on assistance for DMT coverage or are not able to take a DMT as directed or at all due to their current insurance or financial situation.

INDIANAPOLIS—Cognitive behavioral therapy (CBT) can be an effective treatment for psychiatric and interpersonal problems in patients with multiple sclerosis (MS), according to research presented at the 2015 CMSC Annual Meeting. Data indicate that CBT can reduce anxiety and depression and improve marital satisfaction and marital communication.

CBT is a form of psychotherapy that identifies patterns of thought and behavior that change with depression or other mood disorders, said Frederick W. Foley, PhD, Professor of Psychology at Yeshiva University in Bronx, New York. The treatment helps people change these patterns of thinking and behavior to lessen the symptoms of the mood disorder or achieve remission.

Dr. Foley and colleagues examined 40 patients with MS in a study published in Journal of Consulting and Clinical Psychology. The investigators randomized the participants to current available care or stress inoculation training (SIT), which included CBT and progressive deep-muscle relaxation training adapted for patients with MS. At the end of the trial, Dr. Foley and colleagues found that participants randomized to SIT had significantly less depression, anxiety, and distress, compared with participants who received current available care. In addition, individuals randomized to SIT used more problem-focused coping strategies than those randomized to current available care.

In a pilot study published in Multiple Sclerosis in 2001, Dr. Foley and colleagues tested the efficacy of a counseling intervention that included CBT in nine couples with MS and sexual dysfunction. The intervention included 12 counseling sessions, communication with the MS medical treatment team, education, and tailoring of symptomatic treatments so that they would interfere less with sexual function. Repeated measures analysis of variance indicated that the couples had significant improvements in affective and problem-solving communication, marital satisfaction, and sexual satisfaction during the treatment, compared with a phase of the study during which they were on a waiting list. Patients with MS and their spouses reported similar levels of improvement.

CBT also may improve marital communication for patients with MS and cognitive disorders. In a study published in Journal of Neurologic Rehabilitation, Dr. Foley and colleagues developed templates to enable patients and their spouses to communicate. The investigators taught participants listening skills, how to empathize with their spouses using templates, and how to make positive (ie, noncritical) requests. In addition, the researchers instructed participants in how to provide feedback when their spouse’s behavior is not acceptable, as well as how to make positive requests for changes in behavior. This intervention has not been studied in a randomized controlled trial, however.

—Erik Greb

INDIANAPOLIS—Cognitive behavioral therapy (CBT) can be an effective treatment for psychiatric and interpersonal problems in patients with multiple sclerosis (MS), according to research presented at the 2015 CMSC Annual Meeting. Data indicate that CBT can reduce anxiety and depression and improve marital satisfaction and marital communication.

CBT is a form of psychotherapy that identifies patterns of thought and behavior that change with depression or other mood disorders, said Frederick W. Foley, PhD, Professor of Psychology at Yeshiva University in Bronx, New York. The treatment helps people change these patterns of thinking and behavior to lessen the symptoms of the mood disorder or achieve remission.

Dr. Foley and colleagues examined 40 patients with MS in a study published in Journal of Consulting and Clinical Psychology. The investigators randomized the participants to current available care or stress inoculation training (SIT), which included CBT and progressive deep-muscle relaxation training adapted for patients with MS. At the end of the trial, Dr. Foley and colleagues found that participants randomized to SIT had significantly less depression, anxiety, and distress, compared with participants who received current available care. In addition, individuals randomized to SIT used more problem-focused coping strategies than those randomized to current available care.

In a pilot study published in Multiple Sclerosis in 2001, Dr. Foley and colleagues tested the efficacy of a counseling intervention that included CBT in nine couples with MS and sexual dysfunction. The intervention included 12 counseling sessions, communication with the MS medical treatment team, education, and tailoring of symptomatic treatments so that they would interfere less with sexual function. Repeated measures analysis of variance indicated that the couples had significant improvements in affective and problem-solving communication, marital satisfaction, and sexual satisfaction during the treatment, compared with a phase of the study during which they were on a waiting list. Patients with MS and their spouses reported similar levels of improvement.

CBT also may improve marital communication for patients with MS and cognitive disorders. In a study published in Journal of Neurologic Rehabilitation, Dr. Foley and colleagues developed templates to enable patients and their spouses to communicate. The investigators taught participants listening skills, how to empathize with their spouses using templates, and how to make positive (ie, noncritical) requests. In addition, the researchers instructed participants in how to provide feedback when their spouse’s behavior is not acceptable, as well as how to make positive requests for changes in behavior. This intervention has not been studied in a randomized controlled trial, however.

—Erik Greb

INDIANAPOLIS—Cognitive behavioral therapy (CBT) can be an effective treatment for psychiatric and interpersonal problems in patients with multiple sclerosis (MS), according to research presented at the 2015 CMSC Annual Meeting. Data indicate that CBT can reduce anxiety and depression and improve marital satisfaction and marital communication.

CBT is a form of psychotherapy that identifies patterns of thought and behavior that change with depression or other mood disorders, said Frederick W. Foley, PhD, Professor of Psychology at Yeshiva University in Bronx, New York. The treatment helps people change these patterns of thinking and behavior to lessen the symptoms of the mood disorder or achieve remission.

Dr. Foley and colleagues examined 40 patients with MS in a study published in Journal of Consulting and Clinical Psychology. The investigators randomized the participants to current available care or stress inoculation training (SIT), which included CBT and progressive deep-muscle relaxation training adapted for patients with MS. At the end of the trial, Dr. Foley and colleagues found that participants randomized to SIT had significantly less depression, anxiety, and distress, compared with participants who received current available care. In addition, individuals randomized to SIT used more problem-focused coping strategies than those randomized to current available care.

In a pilot study published in Multiple Sclerosis in 2001, Dr. Foley and colleagues tested the efficacy of a counseling intervention that included CBT in nine couples with MS and sexual dysfunction. The intervention included 12 counseling sessions, communication with the MS medical treatment team, education, and tailoring of symptomatic treatments so that they would interfere less with sexual function. Repeated measures analysis of variance indicated that the couples had significant improvements in affective and problem-solving communication, marital satisfaction, and sexual satisfaction during the treatment, compared with a phase of the study during which they were on a waiting list. Patients with MS and their spouses reported similar levels of improvement.

CBT also may improve marital communication for patients with MS and cognitive disorders. In a study published in Journal of Neurologic Rehabilitation, Dr. Foley and colleagues developed templates to enable patients and their spouses to communicate. The investigators taught participants listening skills, how to empathize with their spouses using templates, and how to make positive (ie, noncritical) requests. In addition, the researchers instructed participants in how to provide feedback when their spouse’s behavior is not acceptable, as well as how to make positive requests for changes in behavior. This intervention has not been studied in a randomized controlled trial, however.

—Erik Greb

INDIANAPOLIS—NeuroTrax computerized cognitive testing (NT-CCT) provides an easy, independent, objective screening tool highly predictive of employment status in patients with multiple sclerosis (MS), according to research presented at the 2015 CMSC Annual Meeting. Lead author Mark Gudesblatt, MD, and colleagues said that objective assessment of cognitive function, such as NT-CCT provides, is an important adjunct to Expanded Disability Status Scale (EDSS) in routine MS care. Dr. Gudesblatt is a neurologist at South Shore Neurologic Associates in Patchogue, New York.

Cognitive impairment is common in patients with MS. Routine cognitive screening in MS care, however, is not common. Employment status may be affected by cognitive impairment, but this may not be apparent on routine EDSS assessment. “MS affects cognitive domains differently in people with MS,” said Dr. Gudesblatt. “Easily available and utilized objective cognitive screens are needed to evaluate cognition in MS independent of EDSS or MRI.”

The Symbol Digit Modalities Test (SDMT) is not commonly used in routine MS care. As a single-score cognitive measure, the SDMT does not provide information about individual cognitive domains or the presence or degree of impairment in multiple domains. Computerized cognitive screening tools, in comparison, provide scores for individual cognitive domains.

To explore the predictability and effect size between the SDMT and the NT-CCT domains in patients with MS who self-reported their employment status, Dr. Gudesblatt and colleagues conducted a retrospective review of patients with MS referred for screening cognitive testing in the course of routine clinical care. Patients were evaluated with the oral version of the SDMT and the NT-CCT on the same day.

The study included 113 MS patients, mean age 48.9, and 85% were female. The standardized SDMT score significantly correlated with NT-CCT Global Cognitive Score (GCS) and executive function. The SDMT and NT-CCT GCS both predicted employment status. The effect size of the NT-CCT GCS was 0.83, and for SDMT it was 0.70. For the NT-CCT Executive Function index the effect size was 0.87. In the NeuroTrax Catch Game, with scores standardized for age and education, overall score predicted employment. Unemployed patients with MS had NT-CCT cognitive domain index scores less than one standard deviation below average for cognitively health age and education norms.

“Unemployed patients with MS demonstrated reduced cognitive function relative to employed patients,” Dr. Gudesblatt and colleagues reported. SDMT and NT-CCT screening both significantly differentiate patients with MS who are employed and those who are not. However, NT-CCT predictability of employment provided a greater effect size for this differentiation.

INDIANAPOLIS—NeuroTrax computerized cognitive testing (NT-CCT) provides an easy, independent, objective screening tool highly predictive of employment status in patients with multiple sclerosis (MS), according to research presented at the 2015 CMSC Annual Meeting. Lead author Mark Gudesblatt, MD, and colleagues said that objective assessment of cognitive function, such as NT-CCT provides, is an important adjunct to Expanded Disability Status Scale (EDSS) in routine MS care. Dr. Gudesblatt is a neurologist at South Shore Neurologic Associates in Patchogue, New York.

Cognitive impairment is common in patients with MS. Routine cognitive screening in MS care, however, is not common. Employment status may be affected by cognitive impairment, but this may not be apparent on routine EDSS assessment. “MS affects cognitive domains differently in people with MS,” said Dr. Gudesblatt. “Easily available and utilized objective cognitive screens are needed to evaluate cognition in MS independent of EDSS or MRI.”

The Symbol Digit Modalities Test (SDMT) is not commonly used in routine MS care. As a single-score cognitive measure, the SDMT does not provide information about individual cognitive domains or the presence or degree of impairment in multiple domains. Computerized cognitive screening tools, in comparison, provide scores for individual cognitive domains.

To explore the predictability and effect size between the SDMT and the NT-CCT domains in patients with MS who self-reported their employment status, Dr. Gudesblatt and colleagues conducted a retrospective review of patients with MS referred for screening cognitive testing in the course of routine clinical care. Patients were evaluated with the oral version of the SDMT and the NT-CCT on the same day.

The study included 113 MS patients, mean age 48.9, and 85% were female. The standardized SDMT score significantly correlated with NT-CCT Global Cognitive Score (GCS) and executive function. The SDMT and NT-CCT GCS both predicted employment status. The effect size of the NT-CCT GCS was 0.83, and for SDMT it was 0.70. For the NT-CCT Executive Function index the effect size was 0.87. In the NeuroTrax Catch Game, with scores standardized for age and education, overall score predicted employment. Unemployed patients with MS had NT-CCT cognitive domain index scores less than one standard deviation below average for cognitively health age and education norms.

“Unemployed patients with MS demonstrated reduced cognitive function relative to employed patients,” Dr. Gudesblatt and colleagues reported. SDMT and NT-CCT screening both significantly differentiate patients with MS who are employed and those who are not. However, NT-CCT predictability of employment provided a greater effect size for this differentiation.

INDIANAPOLIS—NeuroTrax computerized cognitive testing (NT-CCT) provides an easy, independent, objective screening tool highly predictive of employment status in patients with multiple sclerosis (MS), according to research presented at the 2015 CMSC Annual Meeting. Lead author Mark Gudesblatt, MD, and colleagues said that objective assessment of cognitive function, such as NT-CCT provides, is an important adjunct to Expanded Disability Status Scale (EDSS) in routine MS care. Dr. Gudesblatt is a neurologist at South Shore Neurologic Associates in Patchogue, New York.

Cognitive impairment is common in patients with MS. Routine cognitive screening in MS care, however, is not common. Employment status may be affected by cognitive impairment, but this may not be apparent on routine EDSS assessment. “MS affects cognitive domains differently in people with MS,” said Dr. Gudesblatt. “Easily available and utilized objective cognitive screens are needed to evaluate cognition in MS independent of EDSS or MRI.”

The Symbol Digit Modalities Test (SDMT) is not commonly used in routine MS care. As a single-score cognitive measure, the SDMT does not provide information about individual cognitive domains or the presence or degree of impairment in multiple domains. Computerized cognitive screening tools, in comparison, provide scores for individual cognitive domains.

To explore the predictability and effect size between the SDMT and the NT-CCT domains in patients with MS who self-reported their employment status, Dr. Gudesblatt and colleagues conducted a retrospective review of patients with MS referred for screening cognitive testing in the course of routine clinical care. Patients were evaluated with the oral version of the SDMT and the NT-CCT on the same day.

The study included 113 MS patients, mean age 48.9, and 85% were female. The standardized SDMT score significantly correlated with NT-CCT Global Cognitive Score (GCS) and executive function. The SDMT and NT-CCT GCS both predicted employment status. The effect size of the NT-CCT GCS was 0.83, and for SDMT it was 0.70. For the NT-CCT Executive Function index the effect size was 0.87. In the NeuroTrax Catch Game, with scores standardized for age and education, overall score predicted employment. Unemployed patients with MS had NT-CCT cognitive domain index scores less than one standard deviation below average for cognitively health age and education norms.

“Unemployed patients with MS demonstrated reduced cognitive function relative to employed patients,” Dr. Gudesblatt and colleagues reported. SDMT and NT-CCT screening both significantly differentiate patients with MS who are employed and those who are not. However, NT-CCT predictability of employment provided a greater effect size for this differentiation.