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Smoldering MS May Warrant Unique Diagnosis, Treatment, and Research Strategies
Smoldering-associated worsening (SAW) of multiple sclerosis (MS) deserves a broader, more comprehensive approach to diagnosis, treatment, and research that goes beyond neurologists’ understanding of progression independent of relapse activity (PIRA), according to a recently published international consensus. However, an outside expert said that promulgating the “smoldering” concept may stoke patient and provider confusion.
Although current disease-modifying therapies (DMTs) for MS exclusively target focal white matter (WM) inflammation, wrote authors lead by Antonio Scalfari, MD, PhD, of Charing Cross Hospital, Imperial College London in England, many people with MS experience worsening disability in a more indolent fashion — despite stable inflammatory markers.
“The gradual accumulation of physical and cognitive disability is driven by smoldering pathological processes via biological substrates, which are different from those of acute focal damage, remain an important unmet therapeutic target,” they wrote.
The same research team first described smoldering MS in a 2022 publication. In the present paper, Scalfari and colleagues reviewed emerging clinical, radiological, and pathological evidence and presented 29 consensus statements in areas ranging from the definition, pathology, and clinical manifestations of smoldering MS to appropriate biomarkers and best clinical practices.
Definition
By definition, the authors wrote, SAW encompasses PIRA but also includes a range of gradually worsening, relapse-independent symptoms that remain undetectable on standard assessments, including the Expanded Disability Status Scale (EDSS) or EDSS-Plus, especially in early disease. To capture symptoms such as subtle motor impairment, cognitive slowing, and fatigue, Scalfari and colleagues recommend tools such as neurological stress tests, fatigue/mood scales, wearable devices, and patient reported outcomes.
Disease Mechanisms
Pathologically, the authors wrote, smoldering MS may stem from intrinsic central nervous system processes that likely incorporate various glial, immune, and neural cells. Smoldering MS also could contribute to aging, and vice versa, the latter possibly through dynamics such as age-related exhaustion of compensatory mechanisms, reduction in remyelination efficiency, and telomere shortening, they added.
Clinical Implementation
Current MS management rests on crude estimates of physical disability and overemphasizes identifying relapses and new MRI lesions as the principal markers of disease activity, wrote Scalfari and colleagues. Instead, they suggested combining motor-associated assessments such as EDSS-Plus with cognitive gauges such as the Brief International Cognitive Assessment for Multiple Sclerosis.
Providers are uncomfortable identifying and discussing smoldering MS, authors allowed, because no licensed treatments target SAW. However, the authors wrote, a principal reason for discussing smoldering MS with patients is to help manage their expectations of current DMTs, which may have little effect on SAW.
‘More Than Lesions’
Bruce Cree, MD, PhD, MAS, professor of neurology at the University of California, San Francisco, said that it is extremely important to raise awareness of physicians’ emerging understanding that “there is more going on in MS than lesions and relapses,” a concept that has been a work in progress for several years. He was not involved with the study but was asked to comment.
A 2019 report on the EPIC cohort coauthored by Cree labeled the disconnect between disability accumulation and relapse occurrence “silent progression.” The observation that disability accumulates in early relapsing MS independent of relapsing activity has been replicated in virtually every dataset worldwide, he added.
“What I don’t like about this article is the reliance on the term ‘smoldering’ and the acceptance that this is an actual phenomenon supported by data.” And authors’ leveraging “smoldering” into additional acronyms such as SAW likely will confuse rather than clarify physicians’ and patients’ understanding of the situation, Cree added. “Clinicians don’t need yet another snappy acronym.” Many are still trying to grasp the PIRA concept in relapsing MS, he said.
“One of the reasons this topic has become so important is that we recognize that even when we have very good control of relapsing disease activity — clinical relapses as well as radiographic large lesion formation on MRI — some patients still develop insidious worsening of disability. And the reasons for that are not well understood,” said Cree.
Accumulating disability absent relapse activity could stem from any number of microscopic inflammatory processes, possibly involving abnormal microglial activation, fibrinogen deposition, microscopic inflammatory infiltrates of CD8-positive T cells, or mitochondrial damage from iron deposition, he said. Or the processes driving PIRA may not even involve inflammation, he added. “We still don’t have a unifying way of understanding how these processes work.”
Cree suspects that, despite investigators’ good intentions, the study’s sponsor, Sanofi, may have influenced the resultant messaging. The company’s tolebrutinib recently completed phase 3 trials in secondary progressive MS and relapsing MS, and a phase 3 trial in primary progressive MS is scheduled for completion in 2025. “A hallmark of Sanofi’s messaging has been this idea that there is smoldering inflammation occurring in MS that tolebrutinib is going to address,” he said.
If clinicians really knew what drove progressive MS, said Cree, “we would be keen on developing therapies targeting that fundamental process. But because we don’t know what’s driving it, we don’t know what to go after.”
The study was supported by Sanofi. Cree is a coauthor of the GEMINI 1 and GEMINI 2 tolebrutinib studies.
A version of this article first appeared on Medscape.com.
Smoldering-associated worsening (SAW) of multiple sclerosis (MS) deserves a broader, more comprehensive approach to diagnosis, treatment, and research that goes beyond neurologists’ understanding of progression independent of relapse activity (PIRA), according to a recently published international consensus. However, an outside expert said that promulgating the “smoldering” concept may stoke patient and provider confusion.
Although current disease-modifying therapies (DMTs) for MS exclusively target focal white matter (WM) inflammation, wrote authors lead by Antonio Scalfari, MD, PhD, of Charing Cross Hospital, Imperial College London in England, many people with MS experience worsening disability in a more indolent fashion — despite stable inflammatory markers.
“The gradual accumulation of physical and cognitive disability is driven by smoldering pathological processes via biological substrates, which are different from those of acute focal damage, remain an important unmet therapeutic target,” they wrote.
The same research team first described smoldering MS in a 2022 publication. In the present paper, Scalfari and colleagues reviewed emerging clinical, radiological, and pathological evidence and presented 29 consensus statements in areas ranging from the definition, pathology, and clinical manifestations of smoldering MS to appropriate biomarkers and best clinical practices.
Definition
By definition, the authors wrote, SAW encompasses PIRA but also includes a range of gradually worsening, relapse-independent symptoms that remain undetectable on standard assessments, including the Expanded Disability Status Scale (EDSS) or EDSS-Plus, especially in early disease. To capture symptoms such as subtle motor impairment, cognitive slowing, and fatigue, Scalfari and colleagues recommend tools such as neurological stress tests, fatigue/mood scales, wearable devices, and patient reported outcomes.
Disease Mechanisms
Pathologically, the authors wrote, smoldering MS may stem from intrinsic central nervous system processes that likely incorporate various glial, immune, and neural cells. Smoldering MS also could contribute to aging, and vice versa, the latter possibly through dynamics such as age-related exhaustion of compensatory mechanisms, reduction in remyelination efficiency, and telomere shortening, they added.
Clinical Implementation
Current MS management rests on crude estimates of physical disability and overemphasizes identifying relapses and new MRI lesions as the principal markers of disease activity, wrote Scalfari and colleagues. Instead, they suggested combining motor-associated assessments such as EDSS-Plus with cognitive gauges such as the Brief International Cognitive Assessment for Multiple Sclerosis.
Providers are uncomfortable identifying and discussing smoldering MS, authors allowed, because no licensed treatments target SAW. However, the authors wrote, a principal reason for discussing smoldering MS with patients is to help manage their expectations of current DMTs, which may have little effect on SAW.
‘More Than Lesions’
Bruce Cree, MD, PhD, MAS, professor of neurology at the University of California, San Francisco, said that it is extremely important to raise awareness of physicians’ emerging understanding that “there is more going on in MS than lesions and relapses,” a concept that has been a work in progress for several years. He was not involved with the study but was asked to comment.
A 2019 report on the EPIC cohort coauthored by Cree labeled the disconnect between disability accumulation and relapse occurrence “silent progression.” The observation that disability accumulates in early relapsing MS independent of relapsing activity has been replicated in virtually every dataset worldwide, he added.
“What I don’t like about this article is the reliance on the term ‘smoldering’ and the acceptance that this is an actual phenomenon supported by data.” And authors’ leveraging “smoldering” into additional acronyms such as SAW likely will confuse rather than clarify physicians’ and patients’ understanding of the situation, Cree added. “Clinicians don’t need yet another snappy acronym.” Many are still trying to grasp the PIRA concept in relapsing MS, he said.
“One of the reasons this topic has become so important is that we recognize that even when we have very good control of relapsing disease activity — clinical relapses as well as radiographic large lesion formation on MRI — some patients still develop insidious worsening of disability. And the reasons for that are not well understood,” said Cree.
Accumulating disability absent relapse activity could stem from any number of microscopic inflammatory processes, possibly involving abnormal microglial activation, fibrinogen deposition, microscopic inflammatory infiltrates of CD8-positive T cells, or mitochondrial damage from iron deposition, he said. Or the processes driving PIRA may not even involve inflammation, he added. “We still don’t have a unifying way of understanding how these processes work.”
Cree suspects that, despite investigators’ good intentions, the study’s sponsor, Sanofi, may have influenced the resultant messaging. The company’s tolebrutinib recently completed phase 3 trials in secondary progressive MS and relapsing MS, and a phase 3 trial in primary progressive MS is scheduled for completion in 2025. “A hallmark of Sanofi’s messaging has been this idea that there is smoldering inflammation occurring in MS that tolebrutinib is going to address,” he said.
If clinicians really knew what drove progressive MS, said Cree, “we would be keen on developing therapies targeting that fundamental process. But because we don’t know what’s driving it, we don’t know what to go after.”
The study was supported by Sanofi. Cree is a coauthor of the GEMINI 1 and GEMINI 2 tolebrutinib studies.
A version of this article first appeared on Medscape.com.
Smoldering-associated worsening (SAW) of multiple sclerosis (MS) deserves a broader, more comprehensive approach to diagnosis, treatment, and research that goes beyond neurologists’ understanding of progression independent of relapse activity (PIRA), according to a recently published international consensus. However, an outside expert said that promulgating the “smoldering” concept may stoke patient and provider confusion.
Although current disease-modifying therapies (DMTs) for MS exclusively target focal white matter (WM) inflammation, wrote authors lead by Antonio Scalfari, MD, PhD, of Charing Cross Hospital, Imperial College London in England, many people with MS experience worsening disability in a more indolent fashion — despite stable inflammatory markers.
“The gradual accumulation of physical and cognitive disability is driven by smoldering pathological processes via biological substrates, which are different from those of acute focal damage, remain an important unmet therapeutic target,” they wrote.
The same research team first described smoldering MS in a 2022 publication. In the present paper, Scalfari and colleagues reviewed emerging clinical, radiological, and pathological evidence and presented 29 consensus statements in areas ranging from the definition, pathology, and clinical manifestations of smoldering MS to appropriate biomarkers and best clinical practices.
Definition
By definition, the authors wrote, SAW encompasses PIRA but also includes a range of gradually worsening, relapse-independent symptoms that remain undetectable on standard assessments, including the Expanded Disability Status Scale (EDSS) or EDSS-Plus, especially in early disease. To capture symptoms such as subtle motor impairment, cognitive slowing, and fatigue, Scalfari and colleagues recommend tools such as neurological stress tests, fatigue/mood scales, wearable devices, and patient reported outcomes.
Disease Mechanisms
Pathologically, the authors wrote, smoldering MS may stem from intrinsic central nervous system processes that likely incorporate various glial, immune, and neural cells. Smoldering MS also could contribute to aging, and vice versa, the latter possibly through dynamics such as age-related exhaustion of compensatory mechanisms, reduction in remyelination efficiency, and telomere shortening, they added.
Clinical Implementation
Current MS management rests on crude estimates of physical disability and overemphasizes identifying relapses and new MRI lesions as the principal markers of disease activity, wrote Scalfari and colleagues. Instead, they suggested combining motor-associated assessments such as EDSS-Plus with cognitive gauges such as the Brief International Cognitive Assessment for Multiple Sclerosis.
Providers are uncomfortable identifying and discussing smoldering MS, authors allowed, because no licensed treatments target SAW. However, the authors wrote, a principal reason for discussing smoldering MS with patients is to help manage their expectations of current DMTs, which may have little effect on SAW.
‘More Than Lesions’
Bruce Cree, MD, PhD, MAS, professor of neurology at the University of California, San Francisco, said that it is extremely important to raise awareness of physicians’ emerging understanding that “there is more going on in MS than lesions and relapses,” a concept that has been a work in progress for several years. He was not involved with the study but was asked to comment.
A 2019 report on the EPIC cohort coauthored by Cree labeled the disconnect between disability accumulation and relapse occurrence “silent progression.” The observation that disability accumulates in early relapsing MS independent of relapsing activity has been replicated in virtually every dataset worldwide, he added.
“What I don’t like about this article is the reliance on the term ‘smoldering’ and the acceptance that this is an actual phenomenon supported by data.” And authors’ leveraging “smoldering” into additional acronyms such as SAW likely will confuse rather than clarify physicians’ and patients’ understanding of the situation, Cree added. “Clinicians don’t need yet another snappy acronym.” Many are still trying to grasp the PIRA concept in relapsing MS, he said.
“One of the reasons this topic has become so important is that we recognize that even when we have very good control of relapsing disease activity — clinical relapses as well as radiographic large lesion formation on MRI — some patients still develop insidious worsening of disability. And the reasons for that are not well understood,” said Cree.
Accumulating disability absent relapse activity could stem from any number of microscopic inflammatory processes, possibly involving abnormal microglial activation, fibrinogen deposition, microscopic inflammatory infiltrates of CD8-positive T cells, or mitochondrial damage from iron deposition, he said. Or the processes driving PIRA may not even involve inflammation, he added. “We still don’t have a unifying way of understanding how these processes work.”
Cree suspects that, despite investigators’ good intentions, the study’s sponsor, Sanofi, may have influenced the resultant messaging. The company’s tolebrutinib recently completed phase 3 trials in secondary progressive MS and relapsing MS, and a phase 3 trial in primary progressive MS is scheduled for completion in 2025. “A hallmark of Sanofi’s messaging has been this idea that there is smoldering inflammation occurring in MS that tolebrutinib is going to address,” he said.
If clinicians really knew what drove progressive MS, said Cree, “we would be keen on developing therapies targeting that fundamental process. But because we don’t know what’s driving it, we don’t know what to go after.”
The study was supported by Sanofi. Cree is a coauthor of the GEMINI 1 and GEMINI 2 tolebrutinib studies.
A version of this article first appeared on Medscape.com.
FROM ANNALS OF NEUROLOGY
sNFl and sGFAP Predict MS Disability in Unique Ways
COPENHAGEN — , according to multiple independent studies.
The basic consensus is that “elevated sNFl levels predict inflammatory-associated worsening, while sGFAP values correlate with progression independent of inflammation,” said Enric Monreal, MD, Immunology Department, Ramón y Cajal University Hospital, Madrid, Spain.
This key message was repeated by several researchers presenting data at the 2024 ECTRIMS 2004 meeting, including one delivered as a latebreaker. There was also general agreement that sGFAP will eventually be a routine prognostic tool even if more data are needed to validate how it will be used in routine MS management.
A New Biomarker for MS Disability Progression
Although apparently reliable for predicting MS disability, “sGFAP is about 5 years behind where we are with sNFl,” said Evan Madill, MD, a clinical research fellow at the Brigham Multiple Sclerosis Research Center, Harvard Medical School, Boston. He does think, however, that it is coming to clinical practice.
In the study he presented, 744 patients from the Brigham MS Research Center database were evaluated retrospectively for sGFAP levels and subsequent disability progression. Among this cohort, for which sGFAP levels were collected at baseline and over time, 46.5% had 6-month confirmed disability progression (CDP) over follow-up.
On univariate analysis, sGFAP levels correlated with and predicted CDP, need for a new ambulatory aid, and conversion to secondary progressive MS (SPMS). For patients less than 60 years of age, all of these correlations were highly significant (P ≤ .002). On multivariate analysis, the significance was preserved for CDP (P = .032) and for need of a new ambulatory aid (P = .007), but it was lost for SPMS conversion.
Notably, his data suggest that a one-time baseline measurement of sGFAP was more useful than change in sGFAP as a predictor.
It is unclear why sGFAP is less predictive in older individuals, but Dr. Madill speculated that non-MS phenomena might play a role at older ages. Treatment did not influence sGFAP levels in this study, but Dr. Madill said most of the data were collected before anti-CD20 monoclonal antibodies were widely available.
The observational study data presented by Dr. Monreal involved 725 patients drawn from 13 European hospitals. sGFAP and sNFl levels were evaluated from blood drawn within 12 months of MS onset. Over time these biomarkers had overlapping but different predictive strengths.
Consistent with previously published studies, which link elevations in sNFl to neuronal damage and elevations in sGFAP to astrogliosis, sGFAP was found to be more useful for predicting progression independent of relapse activity (PIRA), particularly in patients with low sNFl levels.
Increases in sNFl were associated with an increased risk of both PIRA and relapse-associated worsening (RAW), but sNFl was more closely associated with RAW in untreated patients. The risk of PIRA and RAW were similar across GFAP and sNFl levels in those patients treated with high-efficacy disease-modifying therapies (DMT).
Overall, when stratifying the cohort into three groups, those with both low sNFl and low GFAP, those with high sNFl with low GFAP, and those with high GFAP and low sNFl, the relative risks of disability associated with PIRA and RAW diverged, suggesting these biomarkers correlate with different processes of progression.
Comparing sGFAP and sNFl
This same principle was explored further in the latebreaking presentation by Ahmed Abdelhak, MD, a clinical instructor, Weill Institute for Neurosciences, University of California, San Francisco. The objective of his study was to compare sGFAP and sNFl for predicting PIRA in patients on treatment.
The study included 212 patients from the Swiss Multiple Sclerosis Cohort who were started on fingolimod or on B-cell depleting therapies like rituximab. After correcting for sex, age at onset, baseline Expanded Disability Status Scale (EDSS) scores, and other variables, Dr. Abdelhak also reported that the predictive values for PIRA were different for sGFAP relative to sNFl at least on the group level.
However, in this study, unlike the analysis of the Brigham MS Research Center data, changes in sGFAP over time when on treatment did have prognostic value, and there was a relationship between sGFAP levels and treatment. Although reductions in GFAP predicted less disability progression whether patients were treated with fingolimod B-cell depleting therapies, that patterns were different. Dr. Abdelhak, like the other investigators speaking at ECTRIMS, also said the data so far favor sGFAP over sNFl for predicting PIRA.
Each z-score unit change in sGFAP corresponded to a 47% lower risk of PIRA in follow-up over 6.8 years, Dr. Abdelhak reported, adding that the predictive value of sGFAP was “numerically stronger than the corresponding relation for sNFl.”
So far, clinical utility of sGFAP remains speculative. Most of the correlations he presented were on a group rather than the individual level. Moreover, Dr. Abdelhak cautioned that these correlations, based on observational data, do not necessarily reflect causation.
Nonetheless, remarking on the parallels of his data on sGFAP and sNFl with other studies presented at the ECTRIMS meeting, Dr. Abdelhak foresees a time when GFAP will be a prognostic tool, offering relative simplicity and lower cost than the current standard of imaging. He also sees a role in clinical research.
“Monitoring of sGFAP dynamics following DMT initiation could be used to prognosticate long-term PIRA risk and provide insights valuable for design and interpretation of trial outcomes,” he said.
Dr. Monreal reported financial relationships with Almirall, Biogen, Bristol-Myers Squibb, Janssen, Merck, Novartis, Roche, and Sanofi. Dr. Madill and Dr. Abdelhak reported no potential conflicts of interest.
COPENHAGEN — , according to multiple independent studies.
The basic consensus is that “elevated sNFl levels predict inflammatory-associated worsening, while sGFAP values correlate with progression independent of inflammation,” said Enric Monreal, MD, Immunology Department, Ramón y Cajal University Hospital, Madrid, Spain.
This key message was repeated by several researchers presenting data at the 2024 ECTRIMS 2004 meeting, including one delivered as a latebreaker. There was also general agreement that sGFAP will eventually be a routine prognostic tool even if more data are needed to validate how it will be used in routine MS management.
A New Biomarker for MS Disability Progression
Although apparently reliable for predicting MS disability, “sGFAP is about 5 years behind where we are with sNFl,” said Evan Madill, MD, a clinical research fellow at the Brigham Multiple Sclerosis Research Center, Harvard Medical School, Boston. He does think, however, that it is coming to clinical practice.
In the study he presented, 744 patients from the Brigham MS Research Center database were evaluated retrospectively for sGFAP levels and subsequent disability progression. Among this cohort, for which sGFAP levels were collected at baseline and over time, 46.5% had 6-month confirmed disability progression (CDP) over follow-up.
On univariate analysis, sGFAP levels correlated with and predicted CDP, need for a new ambulatory aid, and conversion to secondary progressive MS (SPMS). For patients less than 60 years of age, all of these correlations were highly significant (P ≤ .002). On multivariate analysis, the significance was preserved for CDP (P = .032) and for need of a new ambulatory aid (P = .007), but it was lost for SPMS conversion.
Notably, his data suggest that a one-time baseline measurement of sGFAP was more useful than change in sGFAP as a predictor.
It is unclear why sGFAP is less predictive in older individuals, but Dr. Madill speculated that non-MS phenomena might play a role at older ages. Treatment did not influence sGFAP levels in this study, but Dr. Madill said most of the data were collected before anti-CD20 monoclonal antibodies were widely available.
The observational study data presented by Dr. Monreal involved 725 patients drawn from 13 European hospitals. sGFAP and sNFl levels were evaluated from blood drawn within 12 months of MS onset. Over time these biomarkers had overlapping but different predictive strengths.
Consistent with previously published studies, which link elevations in sNFl to neuronal damage and elevations in sGFAP to astrogliosis, sGFAP was found to be more useful for predicting progression independent of relapse activity (PIRA), particularly in patients with low sNFl levels.
Increases in sNFl were associated with an increased risk of both PIRA and relapse-associated worsening (RAW), but sNFl was more closely associated with RAW in untreated patients. The risk of PIRA and RAW were similar across GFAP and sNFl levels in those patients treated with high-efficacy disease-modifying therapies (DMT).
Overall, when stratifying the cohort into three groups, those with both low sNFl and low GFAP, those with high sNFl with low GFAP, and those with high GFAP and low sNFl, the relative risks of disability associated with PIRA and RAW diverged, suggesting these biomarkers correlate with different processes of progression.
Comparing sGFAP and sNFl
This same principle was explored further in the latebreaking presentation by Ahmed Abdelhak, MD, a clinical instructor, Weill Institute for Neurosciences, University of California, San Francisco. The objective of his study was to compare sGFAP and sNFl for predicting PIRA in patients on treatment.
The study included 212 patients from the Swiss Multiple Sclerosis Cohort who were started on fingolimod or on B-cell depleting therapies like rituximab. After correcting for sex, age at onset, baseline Expanded Disability Status Scale (EDSS) scores, and other variables, Dr. Abdelhak also reported that the predictive values for PIRA were different for sGFAP relative to sNFl at least on the group level.
However, in this study, unlike the analysis of the Brigham MS Research Center data, changes in sGFAP over time when on treatment did have prognostic value, and there was a relationship between sGFAP levels and treatment. Although reductions in GFAP predicted less disability progression whether patients were treated with fingolimod B-cell depleting therapies, that patterns were different. Dr. Abdelhak, like the other investigators speaking at ECTRIMS, also said the data so far favor sGFAP over sNFl for predicting PIRA.
Each z-score unit change in sGFAP corresponded to a 47% lower risk of PIRA in follow-up over 6.8 years, Dr. Abdelhak reported, adding that the predictive value of sGFAP was “numerically stronger than the corresponding relation for sNFl.”
So far, clinical utility of sGFAP remains speculative. Most of the correlations he presented were on a group rather than the individual level. Moreover, Dr. Abdelhak cautioned that these correlations, based on observational data, do not necessarily reflect causation.
Nonetheless, remarking on the parallels of his data on sGFAP and sNFl with other studies presented at the ECTRIMS meeting, Dr. Abdelhak foresees a time when GFAP will be a prognostic tool, offering relative simplicity and lower cost than the current standard of imaging. He also sees a role in clinical research.
“Monitoring of sGFAP dynamics following DMT initiation could be used to prognosticate long-term PIRA risk and provide insights valuable for design and interpretation of trial outcomes,” he said.
Dr. Monreal reported financial relationships with Almirall, Biogen, Bristol-Myers Squibb, Janssen, Merck, Novartis, Roche, and Sanofi. Dr. Madill and Dr. Abdelhak reported no potential conflicts of interest.
COPENHAGEN — , according to multiple independent studies.
The basic consensus is that “elevated sNFl levels predict inflammatory-associated worsening, while sGFAP values correlate with progression independent of inflammation,” said Enric Monreal, MD, Immunology Department, Ramón y Cajal University Hospital, Madrid, Spain.
This key message was repeated by several researchers presenting data at the 2024 ECTRIMS 2004 meeting, including one delivered as a latebreaker. There was also general agreement that sGFAP will eventually be a routine prognostic tool even if more data are needed to validate how it will be used in routine MS management.
A New Biomarker for MS Disability Progression
Although apparently reliable for predicting MS disability, “sGFAP is about 5 years behind where we are with sNFl,” said Evan Madill, MD, a clinical research fellow at the Brigham Multiple Sclerosis Research Center, Harvard Medical School, Boston. He does think, however, that it is coming to clinical practice.
In the study he presented, 744 patients from the Brigham MS Research Center database were evaluated retrospectively for sGFAP levels and subsequent disability progression. Among this cohort, for which sGFAP levels were collected at baseline and over time, 46.5% had 6-month confirmed disability progression (CDP) over follow-up.
On univariate analysis, sGFAP levels correlated with and predicted CDP, need for a new ambulatory aid, and conversion to secondary progressive MS (SPMS). For patients less than 60 years of age, all of these correlations were highly significant (P ≤ .002). On multivariate analysis, the significance was preserved for CDP (P = .032) and for need of a new ambulatory aid (P = .007), but it was lost for SPMS conversion.
Notably, his data suggest that a one-time baseline measurement of sGFAP was more useful than change in sGFAP as a predictor.
It is unclear why sGFAP is less predictive in older individuals, but Dr. Madill speculated that non-MS phenomena might play a role at older ages. Treatment did not influence sGFAP levels in this study, but Dr. Madill said most of the data were collected before anti-CD20 monoclonal antibodies were widely available.
The observational study data presented by Dr. Monreal involved 725 patients drawn from 13 European hospitals. sGFAP and sNFl levels were evaluated from blood drawn within 12 months of MS onset. Over time these biomarkers had overlapping but different predictive strengths.
Consistent with previously published studies, which link elevations in sNFl to neuronal damage and elevations in sGFAP to astrogliosis, sGFAP was found to be more useful for predicting progression independent of relapse activity (PIRA), particularly in patients with low sNFl levels.
Increases in sNFl were associated with an increased risk of both PIRA and relapse-associated worsening (RAW), but sNFl was more closely associated with RAW in untreated patients. The risk of PIRA and RAW were similar across GFAP and sNFl levels in those patients treated with high-efficacy disease-modifying therapies (DMT).
Overall, when stratifying the cohort into three groups, those with both low sNFl and low GFAP, those with high sNFl with low GFAP, and those with high GFAP and low sNFl, the relative risks of disability associated with PIRA and RAW diverged, suggesting these biomarkers correlate with different processes of progression.
Comparing sGFAP and sNFl
This same principle was explored further in the latebreaking presentation by Ahmed Abdelhak, MD, a clinical instructor, Weill Institute for Neurosciences, University of California, San Francisco. The objective of his study was to compare sGFAP and sNFl for predicting PIRA in patients on treatment.
The study included 212 patients from the Swiss Multiple Sclerosis Cohort who were started on fingolimod or on B-cell depleting therapies like rituximab. After correcting for sex, age at onset, baseline Expanded Disability Status Scale (EDSS) scores, and other variables, Dr. Abdelhak also reported that the predictive values for PIRA were different for sGFAP relative to sNFl at least on the group level.
However, in this study, unlike the analysis of the Brigham MS Research Center data, changes in sGFAP over time when on treatment did have prognostic value, and there was a relationship between sGFAP levels and treatment. Although reductions in GFAP predicted less disability progression whether patients were treated with fingolimod B-cell depleting therapies, that patterns were different. Dr. Abdelhak, like the other investigators speaking at ECTRIMS, also said the data so far favor sGFAP over sNFl for predicting PIRA.
Each z-score unit change in sGFAP corresponded to a 47% lower risk of PIRA in follow-up over 6.8 years, Dr. Abdelhak reported, adding that the predictive value of sGFAP was “numerically stronger than the corresponding relation for sNFl.”
So far, clinical utility of sGFAP remains speculative. Most of the correlations he presented were on a group rather than the individual level. Moreover, Dr. Abdelhak cautioned that these correlations, based on observational data, do not necessarily reflect causation.
Nonetheless, remarking on the parallels of his data on sGFAP and sNFl with other studies presented at the ECTRIMS meeting, Dr. Abdelhak foresees a time when GFAP will be a prognostic tool, offering relative simplicity and lower cost than the current standard of imaging. He also sees a role in clinical research.
“Monitoring of sGFAP dynamics following DMT initiation could be used to prognosticate long-term PIRA risk and provide insights valuable for design and interpretation of trial outcomes,” he said.
Dr. Monreal reported financial relationships with Almirall, Biogen, Bristol-Myers Squibb, Janssen, Merck, Novartis, Roche, and Sanofi. Dr. Madill and Dr. Abdelhak reported no potential conflicts of interest.
FROM ECTRIMS 2024
McDonald Criteria Update Aims to Simplify, Speed MS Diagnosis
COPENHAGEN —
Among its recommendations, the expert panel advises incorporating optic nerve imaging for diagnosis and applying stricter criteria for older patients. In addition, it proposes that radiologically isolated syndrome (RIS) may be diagnosed as MS in certain cases and that disease dissemination in time (DIT) should no longer be required.
The proposed criteria changes were presented at the 2024 ECTRIMS annual meeting.
Committee member Xavier Montalban, MD, PhD, from the Department of Neurology and the MS Centre of Catalonia at Vall d’Hebron University Hospital in Barcelona, Spain, told conference attendees that MS is a diagnosis of exclusion.
Brain and spinal cord MRI remains the most useful paraclinical test to diagnose the disease, he said, and an abnormal MRI showing typical lesions is required.
Dr. Montalban noted that optic neuritis is the first manifestation of MS in 25%-35% of cases with clinically isolated syndrome (CIS) — one of the four MS disease courses.
Therefore, he said, the panel is recommending that the optic nerve serve as the “fifth topography” or a fifth anatomical location to demonstrate dissemination in space (DIS) if there’s no better explanation for optic nerve pathology, he said.
Considerable evidence supports the minimal threshold of at least one lesion in at least two of the five topographies after including the optic nerve, he added.
DIS Alone Sufficient?
The panel also concluded that demonstrating DIS alone, without the need for DIT or positive cerebrospinal fluid (CSF), may be sufficient for an MS diagnosis. Currently, both DIS and DIT are required.
The committee broached the topic of RIS, which is identified by the incidental discovery of central nervous system (CNS) white matter T2-weighted hyperintense foci on MRI. These hyperintense foci demonstrate morphological and spatial characteristics highly typical of MS but without clinical symptomatology related to inflammatory demyelination.
Dr. Montalban noted that most patients with RIS will develop MS within 10 years. For these individuals, the panel concluded that the following criteria are sufficient for an MS diagnosis: fulfilling both DIS and DIT; fulfilling DIS and the presence of oligoclonal bands (OCBs) in the cerebrospinal fluid; or fulfilling DIS along with six or more central vein signs (CVS).
The panel proposes the addition of CVS and paramagnetic rim lesions, which are MRI markers of chronic active lesions, as optional tools for MS diagnosis in certain situations. Demonstration of CVS by MRI can increase specificity, said Dr. Montalban.
Evidence also suggests that kappa free light chains (KFLCs) could serve as a valid, simpler, and rater-independent alternative to detecting OCBs, he added. Because KFLCs are interchangeable with OCBs, they can be used in place of OCBs for diagnosing MS through CSF analysis.
Stricter Criteria
The panel is also calling for stricter criteria for confirming an MS diagnosis in those over age 50 or individuals with headache or vascular disorders. In such patients, they strongly recommend additional features such as a spinal cord lesion, positive CSF, and CVS select 6 (six positive lesions).
The panel is also recommending laboratory tests (MOG-IgG Ab) to confirm a diagnosis in children and adolescents. Dr. Montalban noted the presence of CVS in about 50% of T2 lesions strongly suggests MS in this population.
Primary progressive MS (PPMS) requires evidence of clinical progression over at least 12 months. The committee determined that the same criteria for relapsing-remitting MS could be used for PPMS.
Having a single, unified framework of diagnostic criteria will be “very useful,” said Dr. Montalban.
During the same meeting session, Marcello Moccia, MD, PhD, University College London (UCL) Queen Square Institute of Neurology, Faculty of Brain Sciences, London, England, presented examples of patients for whom the revised criteria could be beneficial.
These examples help illustrate how using the new criteria, for example optic nerve imaging, could lead to earlier diagnoses, and, in some cases, easier diagnoses, possibly with less CSF, he said. It could also lead to fewer misdiagnoses, he added, thanks to high-specificity tools.
Implementing the new criteria could offer greater flexibility and reduce complexity, Dr. Moccia concluded, adding that not every patient with suspected MS requires exhaustive testing.
The committee’s next steps will include consulting with the wider MS community and preparing the information for publication, said Dr. Montalban.
Commenting on the proposals, Bruce Bebo, executive vice president of research, National MS Society, agreed the proposed changes to the McDonald Criteria will make diagnosing MS “faster and easier.”
“Importantly, we are providing guidance that is inclusive — how to confirm diagnoses in children, or in people over the age of 50,” said Dr. Bebo. “We’re bringing the latest research and imaging technology to the forefront, to help people with MS get treatment faster, so they can live their best lives.”
Dr. Montalban’s institution has received compensation for lecture honoraria and travel expenses, participation in scientific meetings, clinical trial steering committee membership, or clinical advisory board participation in recent years from AbbVie, Actelion, Alexion, Bial PD, Biogen, Bristol Myers Squibb/Celgene, EMD Serona, Genzyme, Hoffmann-La Roche, Immunic Therapeutics, Janssen Pharmaceuticals, MedDay, Merck, Mylan, Nervgen, Neuraxpharm, Novartis, PeerVoice, Samsung-Biosys Sandoz Sanofi-Genzyme, Teva Pharmaceuticals, TG Therapeutics, EXCEMED, ECTRIMS, MSIF, and NMSS or any of their affiliates. Dr. Moccia reports receiving a salary from University of Naples, Policlinico University Hospital (Naples) and Neurology (US); research grants from MUR PNRR Extended Partnership, ECTRIMS-MAGNIMS, UK MS Society, and Merck; honoraria from AbbVie, Biogen, BMS Celgene, Ipsen, Jansen, Merck, Novartis, Roche, and Sanofi-Genzyme.
A version of this article appeared on Medscape.com.
COPENHAGEN —
Among its recommendations, the expert panel advises incorporating optic nerve imaging for diagnosis and applying stricter criteria for older patients. In addition, it proposes that radiologically isolated syndrome (RIS) may be diagnosed as MS in certain cases and that disease dissemination in time (DIT) should no longer be required.
The proposed criteria changes were presented at the 2024 ECTRIMS annual meeting.
Committee member Xavier Montalban, MD, PhD, from the Department of Neurology and the MS Centre of Catalonia at Vall d’Hebron University Hospital in Barcelona, Spain, told conference attendees that MS is a diagnosis of exclusion.
Brain and spinal cord MRI remains the most useful paraclinical test to diagnose the disease, he said, and an abnormal MRI showing typical lesions is required.
Dr. Montalban noted that optic neuritis is the first manifestation of MS in 25%-35% of cases with clinically isolated syndrome (CIS) — one of the four MS disease courses.
Therefore, he said, the panel is recommending that the optic nerve serve as the “fifth topography” or a fifth anatomical location to demonstrate dissemination in space (DIS) if there’s no better explanation for optic nerve pathology, he said.
Considerable evidence supports the minimal threshold of at least one lesion in at least two of the five topographies after including the optic nerve, he added.
DIS Alone Sufficient?
The panel also concluded that demonstrating DIS alone, without the need for DIT or positive cerebrospinal fluid (CSF), may be sufficient for an MS diagnosis. Currently, both DIS and DIT are required.
The committee broached the topic of RIS, which is identified by the incidental discovery of central nervous system (CNS) white matter T2-weighted hyperintense foci on MRI. These hyperintense foci demonstrate morphological and spatial characteristics highly typical of MS but without clinical symptomatology related to inflammatory demyelination.
Dr. Montalban noted that most patients with RIS will develop MS within 10 years. For these individuals, the panel concluded that the following criteria are sufficient for an MS diagnosis: fulfilling both DIS and DIT; fulfilling DIS and the presence of oligoclonal bands (OCBs) in the cerebrospinal fluid; or fulfilling DIS along with six or more central vein signs (CVS).
The panel proposes the addition of CVS and paramagnetic rim lesions, which are MRI markers of chronic active lesions, as optional tools for MS diagnosis in certain situations. Demonstration of CVS by MRI can increase specificity, said Dr. Montalban.
Evidence also suggests that kappa free light chains (KFLCs) could serve as a valid, simpler, and rater-independent alternative to detecting OCBs, he added. Because KFLCs are interchangeable with OCBs, they can be used in place of OCBs for diagnosing MS through CSF analysis.
Stricter Criteria
The panel is also calling for stricter criteria for confirming an MS diagnosis in those over age 50 or individuals with headache or vascular disorders. In such patients, they strongly recommend additional features such as a spinal cord lesion, positive CSF, and CVS select 6 (six positive lesions).
The panel is also recommending laboratory tests (MOG-IgG Ab) to confirm a diagnosis in children and adolescents. Dr. Montalban noted the presence of CVS in about 50% of T2 lesions strongly suggests MS in this population.
Primary progressive MS (PPMS) requires evidence of clinical progression over at least 12 months. The committee determined that the same criteria for relapsing-remitting MS could be used for PPMS.
Having a single, unified framework of diagnostic criteria will be “very useful,” said Dr. Montalban.
During the same meeting session, Marcello Moccia, MD, PhD, University College London (UCL) Queen Square Institute of Neurology, Faculty of Brain Sciences, London, England, presented examples of patients for whom the revised criteria could be beneficial.
These examples help illustrate how using the new criteria, for example optic nerve imaging, could lead to earlier diagnoses, and, in some cases, easier diagnoses, possibly with less CSF, he said. It could also lead to fewer misdiagnoses, he added, thanks to high-specificity tools.
Implementing the new criteria could offer greater flexibility and reduce complexity, Dr. Moccia concluded, adding that not every patient with suspected MS requires exhaustive testing.
The committee’s next steps will include consulting with the wider MS community and preparing the information for publication, said Dr. Montalban.
Commenting on the proposals, Bruce Bebo, executive vice president of research, National MS Society, agreed the proposed changes to the McDonald Criteria will make diagnosing MS “faster and easier.”
“Importantly, we are providing guidance that is inclusive — how to confirm diagnoses in children, or in people over the age of 50,” said Dr. Bebo. “We’re bringing the latest research and imaging technology to the forefront, to help people with MS get treatment faster, so they can live their best lives.”
Dr. Montalban’s institution has received compensation for lecture honoraria and travel expenses, participation in scientific meetings, clinical trial steering committee membership, or clinical advisory board participation in recent years from AbbVie, Actelion, Alexion, Bial PD, Biogen, Bristol Myers Squibb/Celgene, EMD Serona, Genzyme, Hoffmann-La Roche, Immunic Therapeutics, Janssen Pharmaceuticals, MedDay, Merck, Mylan, Nervgen, Neuraxpharm, Novartis, PeerVoice, Samsung-Biosys Sandoz Sanofi-Genzyme, Teva Pharmaceuticals, TG Therapeutics, EXCEMED, ECTRIMS, MSIF, and NMSS or any of their affiliates. Dr. Moccia reports receiving a salary from University of Naples, Policlinico University Hospital (Naples) and Neurology (US); research grants from MUR PNRR Extended Partnership, ECTRIMS-MAGNIMS, UK MS Society, and Merck; honoraria from AbbVie, Biogen, BMS Celgene, Ipsen, Jansen, Merck, Novartis, Roche, and Sanofi-Genzyme.
A version of this article appeared on Medscape.com.
COPENHAGEN —
Among its recommendations, the expert panel advises incorporating optic nerve imaging for diagnosis and applying stricter criteria for older patients. In addition, it proposes that radiologically isolated syndrome (RIS) may be diagnosed as MS in certain cases and that disease dissemination in time (DIT) should no longer be required.
The proposed criteria changes were presented at the 2024 ECTRIMS annual meeting.
Committee member Xavier Montalban, MD, PhD, from the Department of Neurology and the MS Centre of Catalonia at Vall d’Hebron University Hospital in Barcelona, Spain, told conference attendees that MS is a diagnosis of exclusion.
Brain and spinal cord MRI remains the most useful paraclinical test to diagnose the disease, he said, and an abnormal MRI showing typical lesions is required.
Dr. Montalban noted that optic neuritis is the first manifestation of MS in 25%-35% of cases with clinically isolated syndrome (CIS) — one of the four MS disease courses.
Therefore, he said, the panel is recommending that the optic nerve serve as the “fifth topography” or a fifth anatomical location to demonstrate dissemination in space (DIS) if there’s no better explanation for optic nerve pathology, he said.
Considerable evidence supports the minimal threshold of at least one lesion in at least two of the five topographies after including the optic nerve, he added.
DIS Alone Sufficient?
The panel also concluded that demonstrating DIS alone, without the need for DIT or positive cerebrospinal fluid (CSF), may be sufficient for an MS diagnosis. Currently, both DIS and DIT are required.
The committee broached the topic of RIS, which is identified by the incidental discovery of central nervous system (CNS) white matter T2-weighted hyperintense foci on MRI. These hyperintense foci demonstrate morphological and spatial characteristics highly typical of MS but without clinical symptomatology related to inflammatory demyelination.
Dr. Montalban noted that most patients with RIS will develop MS within 10 years. For these individuals, the panel concluded that the following criteria are sufficient for an MS diagnosis: fulfilling both DIS and DIT; fulfilling DIS and the presence of oligoclonal bands (OCBs) in the cerebrospinal fluid; or fulfilling DIS along with six or more central vein signs (CVS).
The panel proposes the addition of CVS and paramagnetic rim lesions, which are MRI markers of chronic active lesions, as optional tools for MS diagnosis in certain situations. Demonstration of CVS by MRI can increase specificity, said Dr. Montalban.
Evidence also suggests that kappa free light chains (KFLCs) could serve as a valid, simpler, and rater-independent alternative to detecting OCBs, he added. Because KFLCs are interchangeable with OCBs, they can be used in place of OCBs for diagnosing MS through CSF analysis.
Stricter Criteria
The panel is also calling for stricter criteria for confirming an MS diagnosis in those over age 50 or individuals with headache or vascular disorders. In such patients, they strongly recommend additional features such as a spinal cord lesion, positive CSF, and CVS select 6 (six positive lesions).
The panel is also recommending laboratory tests (MOG-IgG Ab) to confirm a diagnosis in children and adolescents. Dr. Montalban noted the presence of CVS in about 50% of T2 lesions strongly suggests MS in this population.
Primary progressive MS (PPMS) requires evidence of clinical progression over at least 12 months. The committee determined that the same criteria for relapsing-remitting MS could be used for PPMS.
Having a single, unified framework of diagnostic criteria will be “very useful,” said Dr. Montalban.
During the same meeting session, Marcello Moccia, MD, PhD, University College London (UCL) Queen Square Institute of Neurology, Faculty of Brain Sciences, London, England, presented examples of patients for whom the revised criteria could be beneficial.
These examples help illustrate how using the new criteria, for example optic nerve imaging, could lead to earlier diagnoses, and, in some cases, easier diagnoses, possibly with less CSF, he said. It could also lead to fewer misdiagnoses, he added, thanks to high-specificity tools.
Implementing the new criteria could offer greater flexibility and reduce complexity, Dr. Moccia concluded, adding that not every patient with suspected MS requires exhaustive testing.
The committee’s next steps will include consulting with the wider MS community and preparing the information for publication, said Dr. Montalban.
Commenting on the proposals, Bruce Bebo, executive vice president of research, National MS Society, agreed the proposed changes to the McDonald Criteria will make diagnosing MS “faster and easier.”
“Importantly, we are providing guidance that is inclusive — how to confirm diagnoses in children, or in people over the age of 50,” said Dr. Bebo. “We’re bringing the latest research and imaging technology to the forefront, to help people with MS get treatment faster, so they can live their best lives.”
Dr. Montalban’s institution has received compensation for lecture honoraria and travel expenses, participation in scientific meetings, clinical trial steering committee membership, or clinical advisory board participation in recent years from AbbVie, Actelion, Alexion, Bial PD, Biogen, Bristol Myers Squibb/Celgene, EMD Serona, Genzyme, Hoffmann-La Roche, Immunic Therapeutics, Janssen Pharmaceuticals, MedDay, Merck, Mylan, Nervgen, Neuraxpharm, Novartis, PeerVoice, Samsung-Biosys Sandoz Sanofi-Genzyme, Teva Pharmaceuticals, TG Therapeutics, EXCEMED, ECTRIMS, MSIF, and NMSS or any of their affiliates. Dr. Moccia reports receiving a salary from University of Naples, Policlinico University Hospital (Naples) and Neurology (US); research grants from MUR PNRR Extended Partnership, ECTRIMS-MAGNIMS, UK MS Society, and Merck; honoraria from AbbVie, Biogen, BMS Celgene, Ipsen, Jansen, Merck, Novartis, Roche, and Sanofi-Genzyme.
A version of this article appeared on Medscape.com.
FROM ECTRIMS 2024
Genetically Driven Depression Tied to Increased MS Disease Activity
COPENHAGEN — , early results of a new study showed.
Unlike the previous research, the current analysis used polygenic risk scores for depression, which summarize the estimated effect of genetic variants to determine the potential association with MS disease activity, so results are less likely to be explained by reverse causality.
This study increases awareness of the link between depression and MS, said study investigator Kaarina Kowalec, PhD, assistant professor, College of Pharmacy, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada. “We’re starting to understand how depression affects relapses and disability progression in MS,” she said.
The findings were presented at the 2024 ECTRIMS annual meeting.
Common Comorbidity
Depression is a common comorbidity in patients with MS and is associated with increased relapse and disability progression. Depression risk is partly polygenic in nature, involving numerous common genetic variants, said Dr. Kowalec.
The case-control study included 3420 relapsing-onset MS cases of European ancestry from four existing cohorts in three countries.
The Canadian cohort included those enrolled in a prospective longitudinal study of psychiatric comorbidity in chronic immune-mediated inflammatory disease (IMID), including MS; the Swedish cohort was an MS registry (SSReg) that encompasses 64 MS clinics (the cohort was split into two groups); and the US cohort was enrolled in a clinical trial of combined therapy with interferon and glatiramer acetate (CombiRx) in patients with MS.
The median follow-up in these cohorts ranged from 3 to 5 years.
Not surprisingly, most participants were women (from 71% in one of the Swedish cohorts to 83% in the Canadian cohort), and the age at MS onset ranged from 29 years in the Canadian cohort to 35 years in one of the Swedish cohorts.
The median baseline Expanded Disability Status Scale (EDSS) score was higher in the Canadian cohort (3.5) than in the Swedish (1.5) and US (2.0) cohorts, “reflective of the Canadian cohort being slightly more progressed,” said Dr. Kowalec.
Inherited Variants
To measure depression heritability, researchers generated a polygenic risk score in whole-genome imputed genotypes. The score reflects the number of inherited common genetic variants, weighted by effect sizes.
Researchers investigated the association between depression polygenic risk scores (top 20% vs. bottom 80%) with annualized relapse rate and worsening disability in MS measured by the rate of change in EDSS score. In the US cohort, they also explored the association between depression polygenic risk scores and time to relapse and confirmed EDSS worsening.
Covariates included use of disease-modifying therapy, age, sex, and the first five genetic ancestry principal components. The latter was done to capture residual stratification by genetic ancestry, although Dr. Kowalec stressed analyses were done only in those of European ancestry.
Investigators found a higher depression polygenic risk score was associated with relapse risk (incident rate ratio, 1.23; 95% CI, 1.01-1.49).
“Essentially, for every one standard deviation increase in the depression polygenic score, we found a significant increased hazard of 23% for experiencing a relapse over the follow-up period,” said Dr. Kowalec, who is also affiliated with the Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.
She noted the Canadian cohort did not have many relapses, while the US and Swedish cohorts “had an increased rate.”
Other analyses examined the risk of having a relapse or worsening disability. Every one SD increase in the depression polygenic risk score was significantly associated with a 2.2 greater risk of experiencing relapse (hazard ratio [HR], 2.20; 95% CI, 1.35-3.60) and a 51% increased risk for confirmed EDSS progression (HR, 1.51; 95% CI, 1.03-2.22).
‘An Ideal Marker’
Use of polygenetic risk scores reduces the possibility of reverse causation, noted Dr. Kowalec. “These markers are fixed at birth and don’t change over your lifespan, so they’re really an ideal marker.”
The results suggest polygenetic risk scores represent a potential biomarker for risk stratification in people with MS, said Dr. Kowalec. Although depression polygenic risk scores are not currently available in clinical practice, “I would hope this would change in the next 3-4 years,” she said.
Asked by a delegate if confounding by a third variable is possible, Dr. Kowalec said because genetic markers don’t change over time, there is a hint that the direction is causal and that depression is driving the outcome. However, she added, further confirmation is needed.
Dr. Kowalec noted that there were no data on antidepressant use but noted that about half of the Canadian and US cohorts — and likely the same number in the Swedish cohorts — self-reported depression.
A limitation of the study was that it included only participants of European ancestry.
Clinical Implications Unclear
Commenting on the research, Lauren Gluck, MD, program director, Montefiore Multiple Sclerosis Center, Bronx, New York, described the study as “fascinating” but noted that it’s unclear how to use this new information in clinical practice.
“Clinicians frequently ask people with MS about mood symptoms and offer interventions like antidepressants and referrals to therapists. However, genetic testing is not routine, so we don’t yet know who to target based on these data.”
Preexisting depression or more severe depression could be viewed as a “red flag” for risk for more disease activity in the future, she said.
“This could encourage clinicians to use more highly effective therapy in these patients, similar to our strategies for people with MS with frequent attacks and more disease burden on MRIs.”
The study received support from the Consortium of Multiple Sclerosis Centers and the Congressionally Directed Medical Research Programs, Department of Defense.
Dr. Kowalec reported no relevant conflicts of interest.
A version of this article appeared on Medscape.com.
COPENHAGEN — , early results of a new study showed.
Unlike the previous research, the current analysis used polygenic risk scores for depression, which summarize the estimated effect of genetic variants to determine the potential association with MS disease activity, so results are less likely to be explained by reverse causality.
This study increases awareness of the link between depression and MS, said study investigator Kaarina Kowalec, PhD, assistant professor, College of Pharmacy, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada. “We’re starting to understand how depression affects relapses and disability progression in MS,” she said.
The findings were presented at the 2024 ECTRIMS annual meeting.
Common Comorbidity
Depression is a common comorbidity in patients with MS and is associated with increased relapse and disability progression. Depression risk is partly polygenic in nature, involving numerous common genetic variants, said Dr. Kowalec.
The case-control study included 3420 relapsing-onset MS cases of European ancestry from four existing cohorts in three countries.
The Canadian cohort included those enrolled in a prospective longitudinal study of psychiatric comorbidity in chronic immune-mediated inflammatory disease (IMID), including MS; the Swedish cohort was an MS registry (SSReg) that encompasses 64 MS clinics (the cohort was split into two groups); and the US cohort was enrolled in a clinical trial of combined therapy with interferon and glatiramer acetate (CombiRx) in patients with MS.
The median follow-up in these cohorts ranged from 3 to 5 years.
Not surprisingly, most participants were women (from 71% in one of the Swedish cohorts to 83% in the Canadian cohort), and the age at MS onset ranged from 29 years in the Canadian cohort to 35 years in one of the Swedish cohorts.
The median baseline Expanded Disability Status Scale (EDSS) score was higher in the Canadian cohort (3.5) than in the Swedish (1.5) and US (2.0) cohorts, “reflective of the Canadian cohort being slightly more progressed,” said Dr. Kowalec.
Inherited Variants
To measure depression heritability, researchers generated a polygenic risk score in whole-genome imputed genotypes. The score reflects the number of inherited common genetic variants, weighted by effect sizes.
Researchers investigated the association between depression polygenic risk scores (top 20% vs. bottom 80%) with annualized relapse rate and worsening disability in MS measured by the rate of change in EDSS score. In the US cohort, they also explored the association between depression polygenic risk scores and time to relapse and confirmed EDSS worsening.
Covariates included use of disease-modifying therapy, age, sex, and the first five genetic ancestry principal components. The latter was done to capture residual stratification by genetic ancestry, although Dr. Kowalec stressed analyses were done only in those of European ancestry.
Investigators found a higher depression polygenic risk score was associated with relapse risk (incident rate ratio, 1.23; 95% CI, 1.01-1.49).
“Essentially, for every one standard deviation increase in the depression polygenic score, we found a significant increased hazard of 23% for experiencing a relapse over the follow-up period,” said Dr. Kowalec, who is also affiliated with the Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.
She noted the Canadian cohort did not have many relapses, while the US and Swedish cohorts “had an increased rate.”
Other analyses examined the risk of having a relapse or worsening disability. Every one SD increase in the depression polygenic risk score was significantly associated with a 2.2 greater risk of experiencing relapse (hazard ratio [HR], 2.20; 95% CI, 1.35-3.60) and a 51% increased risk for confirmed EDSS progression (HR, 1.51; 95% CI, 1.03-2.22).
‘An Ideal Marker’
Use of polygenetic risk scores reduces the possibility of reverse causation, noted Dr. Kowalec. “These markers are fixed at birth and don’t change over your lifespan, so they’re really an ideal marker.”
The results suggest polygenetic risk scores represent a potential biomarker for risk stratification in people with MS, said Dr. Kowalec. Although depression polygenic risk scores are not currently available in clinical practice, “I would hope this would change in the next 3-4 years,” she said.
Asked by a delegate if confounding by a third variable is possible, Dr. Kowalec said because genetic markers don’t change over time, there is a hint that the direction is causal and that depression is driving the outcome. However, she added, further confirmation is needed.
Dr. Kowalec noted that there were no data on antidepressant use but noted that about half of the Canadian and US cohorts — and likely the same number in the Swedish cohorts — self-reported depression.
A limitation of the study was that it included only participants of European ancestry.
Clinical Implications Unclear
Commenting on the research, Lauren Gluck, MD, program director, Montefiore Multiple Sclerosis Center, Bronx, New York, described the study as “fascinating” but noted that it’s unclear how to use this new information in clinical practice.
“Clinicians frequently ask people with MS about mood symptoms and offer interventions like antidepressants and referrals to therapists. However, genetic testing is not routine, so we don’t yet know who to target based on these data.”
Preexisting depression or more severe depression could be viewed as a “red flag” for risk for more disease activity in the future, she said.
“This could encourage clinicians to use more highly effective therapy in these patients, similar to our strategies for people with MS with frequent attacks and more disease burden on MRIs.”
The study received support from the Consortium of Multiple Sclerosis Centers and the Congressionally Directed Medical Research Programs, Department of Defense.
Dr. Kowalec reported no relevant conflicts of interest.
A version of this article appeared on Medscape.com.
COPENHAGEN — , early results of a new study showed.
Unlike the previous research, the current analysis used polygenic risk scores for depression, which summarize the estimated effect of genetic variants to determine the potential association with MS disease activity, so results are less likely to be explained by reverse causality.
This study increases awareness of the link between depression and MS, said study investigator Kaarina Kowalec, PhD, assistant professor, College of Pharmacy, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada. “We’re starting to understand how depression affects relapses and disability progression in MS,” she said.
The findings were presented at the 2024 ECTRIMS annual meeting.
Common Comorbidity
Depression is a common comorbidity in patients with MS and is associated with increased relapse and disability progression. Depression risk is partly polygenic in nature, involving numerous common genetic variants, said Dr. Kowalec.
The case-control study included 3420 relapsing-onset MS cases of European ancestry from four existing cohorts in three countries.
The Canadian cohort included those enrolled in a prospective longitudinal study of psychiatric comorbidity in chronic immune-mediated inflammatory disease (IMID), including MS; the Swedish cohort was an MS registry (SSReg) that encompasses 64 MS clinics (the cohort was split into two groups); and the US cohort was enrolled in a clinical trial of combined therapy with interferon and glatiramer acetate (CombiRx) in patients with MS.
The median follow-up in these cohorts ranged from 3 to 5 years.
Not surprisingly, most participants were women (from 71% in one of the Swedish cohorts to 83% in the Canadian cohort), and the age at MS onset ranged from 29 years in the Canadian cohort to 35 years in one of the Swedish cohorts.
The median baseline Expanded Disability Status Scale (EDSS) score was higher in the Canadian cohort (3.5) than in the Swedish (1.5) and US (2.0) cohorts, “reflective of the Canadian cohort being slightly more progressed,” said Dr. Kowalec.
Inherited Variants
To measure depression heritability, researchers generated a polygenic risk score in whole-genome imputed genotypes. The score reflects the number of inherited common genetic variants, weighted by effect sizes.
Researchers investigated the association between depression polygenic risk scores (top 20% vs. bottom 80%) with annualized relapse rate and worsening disability in MS measured by the rate of change in EDSS score. In the US cohort, they also explored the association between depression polygenic risk scores and time to relapse and confirmed EDSS worsening.
Covariates included use of disease-modifying therapy, age, sex, and the first five genetic ancestry principal components. The latter was done to capture residual stratification by genetic ancestry, although Dr. Kowalec stressed analyses were done only in those of European ancestry.
Investigators found a higher depression polygenic risk score was associated with relapse risk (incident rate ratio, 1.23; 95% CI, 1.01-1.49).
“Essentially, for every one standard deviation increase in the depression polygenic score, we found a significant increased hazard of 23% for experiencing a relapse over the follow-up period,” said Dr. Kowalec, who is also affiliated with the Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.
She noted the Canadian cohort did not have many relapses, while the US and Swedish cohorts “had an increased rate.”
Other analyses examined the risk of having a relapse or worsening disability. Every one SD increase in the depression polygenic risk score was significantly associated with a 2.2 greater risk of experiencing relapse (hazard ratio [HR], 2.20; 95% CI, 1.35-3.60) and a 51% increased risk for confirmed EDSS progression (HR, 1.51; 95% CI, 1.03-2.22).
‘An Ideal Marker’
Use of polygenetic risk scores reduces the possibility of reverse causation, noted Dr. Kowalec. “These markers are fixed at birth and don’t change over your lifespan, so they’re really an ideal marker.”
The results suggest polygenetic risk scores represent a potential biomarker for risk stratification in people with MS, said Dr. Kowalec. Although depression polygenic risk scores are not currently available in clinical practice, “I would hope this would change in the next 3-4 years,” she said.
Asked by a delegate if confounding by a third variable is possible, Dr. Kowalec said because genetic markers don’t change over time, there is a hint that the direction is causal and that depression is driving the outcome. However, she added, further confirmation is needed.
Dr. Kowalec noted that there were no data on antidepressant use but noted that about half of the Canadian and US cohorts — and likely the same number in the Swedish cohorts — self-reported depression.
A limitation of the study was that it included only participants of European ancestry.
Clinical Implications Unclear
Commenting on the research, Lauren Gluck, MD, program director, Montefiore Multiple Sclerosis Center, Bronx, New York, described the study as “fascinating” but noted that it’s unclear how to use this new information in clinical practice.
“Clinicians frequently ask people with MS about mood symptoms and offer interventions like antidepressants and referrals to therapists. However, genetic testing is not routine, so we don’t yet know who to target based on these data.”
Preexisting depression or more severe depression could be viewed as a “red flag” for risk for more disease activity in the future, she said.
“This could encourage clinicians to use more highly effective therapy in these patients, similar to our strategies for people with MS with frequent attacks and more disease burden on MRIs.”
The study received support from the Consortium of Multiple Sclerosis Centers and the Congressionally Directed Medical Research Programs, Department of Defense.
Dr. Kowalec reported no relevant conflicts of interest.
A version of this article appeared on Medscape.com.
FROM ECTRIMS 2024
Ofatumumab MS Study Supports Early Start Over Switch
COPENHAGEN — according to extension data out to 6 years.
By the most recent analysis of a phase 3 extension study, there were “fewer disability worsening events and greater likelihood of being progression free among those started on ofatumumab than those started on teriflunomide and switched,” reported Amit Bar-Or, MD, director of the Center of Neuroinflammation and Neurotherapeutics, University of Pennsylvania, Philadelphia.
Stated differently, if ofatumumab is delayed, it never fully compensates for the advantage of better early MS control in treatment-naïve patients, according to Dr. Bar-Or, who presented these data at the 2024 ECTRIMS annual meeting.
Anti-CD20 Disability Protection Already Seen in Pivotal Trial
In two phase 3 trials called ASCLEPIOS I and II that were published together several years ago in The New England Journal of Medicine, the anti-CD20 monoclonal antibody ofatumumab reduced the annualized relapse rate (ARR) by half (0.11 vs. 0.22). While ARR was the primary endpoint, ofatumumab was also associated with a 34% reduction (P = .002) in risk of confirmed disability worsening at 3 months (3mCDW) at a medium follow-up of 1.6 years.
After the completion of ASCLEPIOS I and II, the majority of both arms of the study were enrolled in the ALITHIOS extension study. Patients in ofatumumab arm have remained on their initially assigned drug. Patients in the teriflunomide group were switched. Characterized as the delayed ofatumumab group, they have been receiving the same 20-mg, once-monthly subcutaneous (SQ) dose of ofatumumab as those initially assigned to this drug. ALITHIOS will continue to follow both groups until 2028.
Patients have now been followed for up to 6 years. In the latest results presented at ECTRIMS, data were available for 690 patients on continuous treatment and 677 switch patients. Baseline characteristics of the two groups were similar. About half of each group were treatment naive when enrolled in the ASCLEPIOS trials.
Whether compared for 6-month confirmed disability worsening (6mCDW), 6-month progression independent of relapse activity (6mPIRA) or 6-month relapse-associated worsening (6mRAW), disease progression was consistently worse for those with delayed ofatumumab. The differences were most pronounced in those who were treatment naive when started on therapy.
Anti-CD20 MAB sustains Disability Protection for up to Years
For those who were treatment naive, the rates of 6mCDW at the most recent follow-up were 16.61% vs 23.74% (P = .033) for continuous and delayed ofatumumab, respectively. For the entire study, these rates were 21.09% versus 24.77%, respectively, which represented a strong trend (P = .063).
The relative rates for 6mPIRA (11.12% vs 16.75%) and 6mRAW (4.26% vs 4.82%) in treatment-naive patients also favored continuous over delayed ofatumumab, and the numerical advantage was also seen with up to 6 years of follow-up in the overall study population for 6mPIRA (15.45% vs 16.56%) and 6mRAW (5.24% vs 5.81%).
Translating these into freedom from disability, Dr. Bar-Or reported that more than 80% (83.4%) of patients on continuous ofatumumab were progression free for up to 6 years, a figure that exceeded the 76.3% free of progression in the delayed ofatumumab group.
On the basis of 6mPIRA, that absence of disability progression neared 90% (88.9%) on continuous ofatumumab relative to 83.3% for delayed ofatumumab.
An advantage for a reduction in disability accumulation for ofatumumab relative to teriflunomide was established at the end of the ASCLEPIOS I and II trial, but the latest follow-up shows that it is “sustained out to 6 years.” The advantage is achieved with no greater cost in adverse events during the early treatment period, according to Dr. Bar-Or, who noted that ofatumumab and teriflunomide were similarly well tolerated in ASCLEPIOS I and II.
No New Gd T1 Lesions Observed Over 12 Months
Although other anti-CD20 monoclonal antibodies have also been shown to be highly effective and often more effective than immunomodulators in the first- and second-line treatment of relapsing remitting MS (RRMS), another set of data presented at ECTRIMS 2024 looked specifically at transitioning from intravenous (IV) anti-CD20 drugs to SQ ofatumumab.
In this study, called OLIKOS, 102 RRMS patients who had received either IV ocrelizumab or IV rituximab were followed after transitioning to ofatumumab administered SQ with an autoinjector pen. The primary endpoint was the proportion of patients with no change or a reduction gadolinium-enhancing (Gd) T1 lesions over 12 months of follow-up.
“At month 12, 84 of 84 evaluable patients with evaluable MRI assessments met the primary endpoint,” reported the principal investigator Le Hua, MD, director of the Multiple Sclerosis Program, Cleveland Clinic in Ohio.
At 12 months, there were also no new or enlarging T2 lesions in 98% of patients receiving SQ ofatumumab following the transition from one of the other anti-CD20 IV drugs, but Dr. Hua characterized this as an exploratory endpoint.
The safety and tolerability data during the OLIKOS study was also reassuring with no new or unexpected safety signals for SQ ofatumumab, which has been well tolerated in the phase 3 development program. IgM and IgG levels remained stable over the course of follow-up.
High-efficacy anti-CD20 drugs were once reserved for RRMS patients with highly active disease, but long-term data, such as those generated by the ALITHIOS extension study, suggest greater efficacy with acceptable safety of these agents relative to conventional first-line RRMS therapies. Based on ALITHIOS data, Dr. Bar-Or suggested that early use of the most effective therapy appears to lead to better long-term protection from increased cumulative disability.
Dr. Bar-Or reported financial relationships with Accure, Atara, Biogen, Bristol-Myers Squibb, Celgene, GlaxoSmithKline, Gossamer, Janssen/Actelion, Medimmune, Merck/EMD Serono, Novartis, Roche/Genentech, and Sanofi-Genzyme. Dr. Hua reported financial relationships with Alexion, EMD Serono, Genentech, Horizon, Novartis, and TG Therapeutics.
COPENHAGEN — according to extension data out to 6 years.
By the most recent analysis of a phase 3 extension study, there were “fewer disability worsening events and greater likelihood of being progression free among those started on ofatumumab than those started on teriflunomide and switched,” reported Amit Bar-Or, MD, director of the Center of Neuroinflammation and Neurotherapeutics, University of Pennsylvania, Philadelphia.
Stated differently, if ofatumumab is delayed, it never fully compensates for the advantage of better early MS control in treatment-naïve patients, according to Dr. Bar-Or, who presented these data at the 2024 ECTRIMS annual meeting.
Anti-CD20 Disability Protection Already Seen in Pivotal Trial
In two phase 3 trials called ASCLEPIOS I and II that were published together several years ago in The New England Journal of Medicine, the anti-CD20 monoclonal antibody ofatumumab reduced the annualized relapse rate (ARR) by half (0.11 vs. 0.22). While ARR was the primary endpoint, ofatumumab was also associated with a 34% reduction (P = .002) in risk of confirmed disability worsening at 3 months (3mCDW) at a medium follow-up of 1.6 years.
After the completion of ASCLEPIOS I and II, the majority of both arms of the study were enrolled in the ALITHIOS extension study. Patients in ofatumumab arm have remained on their initially assigned drug. Patients in the teriflunomide group were switched. Characterized as the delayed ofatumumab group, they have been receiving the same 20-mg, once-monthly subcutaneous (SQ) dose of ofatumumab as those initially assigned to this drug. ALITHIOS will continue to follow both groups until 2028.
Patients have now been followed for up to 6 years. In the latest results presented at ECTRIMS, data were available for 690 patients on continuous treatment and 677 switch patients. Baseline characteristics of the two groups were similar. About half of each group were treatment naive when enrolled in the ASCLEPIOS trials.
Whether compared for 6-month confirmed disability worsening (6mCDW), 6-month progression independent of relapse activity (6mPIRA) or 6-month relapse-associated worsening (6mRAW), disease progression was consistently worse for those with delayed ofatumumab. The differences were most pronounced in those who were treatment naive when started on therapy.
Anti-CD20 MAB sustains Disability Protection for up to Years
For those who were treatment naive, the rates of 6mCDW at the most recent follow-up were 16.61% vs 23.74% (P = .033) for continuous and delayed ofatumumab, respectively. For the entire study, these rates were 21.09% versus 24.77%, respectively, which represented a strong trend (P = .063).
The relative rates for 6mPIRA (11.12% vs 16.75%) and 6mRAW (4.26% vs 4.82%) in treatment-naive patients also favored continuous over delayed ofatumumab, and the numerical advantage was also seen with up to 6 years of follow-up in the overall study population for 6mPIRA (15.45% vs 16.56%) and 6mRAW (5.24% vs 5.81%).
Translating these into freedom from disability, Dr. Bar-Or reported that more than 80% (83.4%) of patients on continuous ofatumumab were progression free for up to 6 years, a figure that exceeded the 76.3% free of progression in the delayed ofatumumab group.
On the basis of 6mPIRA, that absence of disability progression neared 90% (88.9%) on continuous ofatumumab relative to 83.3% for delayed ofatumumab.
An advantage for a reduction in disability accumulation for ofatumumab relative to teriflunomide was established at the end of the ASCLEPIOS I and II trial, but the latest follow-up shows that it is “sustained out to 6 years.” The advantage is achieved with no greater cost in adverse events during the early treatment period, according to Dr. Bar-Or, who noted that ofatumumab and teriflunomide were similarly well tolerated in ASCLEPIOS I and II.
No New Gd T1 Lesions Observed Over 12 Months
Although other anti-CD20 monoclonal antibodies have also been shown to be highly effective and often more effective than immunomodulators in the first- and second-line treatment of relapsing remitting MS (RRMS), another set of data presented at ECTRIMS 2024 looked specifically at transitioning from intravenous (IV) anti-CD20 drugs to SQ ofatumumab.
In this study, called OLIKOS, 102 RRMS patients who had received either IV ocrelizumab or IV rituximab were followed after transitioning to ofatumumab administered SQ with an autoinjector pen. The primary endpoint was the proportion of patients with no change or a reduction gadolinium-enhancing (Gd) T1 lesions over 12 months of follow-up.
“At month 12, 84 of 84 evaluable patients with evaluable MRI assessments met the primary endpoint,” reported the principal investigator Le Hua, MD, director of the Multiple Sclerosis Program, Cleveland Clinic in Ohio.
At 12 months, there were also no new or enlarging T2 lesions in 98% of patients receiving SQ ofatumumab following the transition from one of the other anti-CD20 IV drugs, but Dr. Hua characterized this as an exploratory endpoint.
The safety and tolerability data during the OLIKOS study was also reassuring with no new or unexpected safety signals for SQ ofatumumab, which has been well tolerated in the phase 3 development program. IgM and IgG levels remained stable over the course of follow-up.
High-efficacy anti-CD20 drugs were once reserved for RRMS patients with highly active disease, but long-term data, such as those generated by the ALITHIOS extension study, suggest greater efficacy with acceptable safety of these agents relative to conventional first-line RRMS therapies. Based on ALITHIOS data, Dr. Bar-Or suggested that early use of the most effective therapy appears to lead to better long-term protection from increased cumulative disability.
Dr. Bar-Or reported financial relationships with Accure, Atara, Biogen, Bristol-Myers Squibb, Celgene, GlaxoSmithKline, Gossamer, Janssen/Actelion, Medimmune, Merck/EMD Serono, Novartis, Roche/Genentech, and Sanofi-Genzyme. Dr. Hua reported financial relationships with Alexion, EMD Serono, Genentech, Horizon, Novartis, and TG Therapeutics.
COPENHAGEN — according to extension data out to 6 years.
By the most recent analysis of a phase 3 extension study, there were “fewer disability worsening events and greater likelihood of being progression free among those started on ofatumumab than those started on teriflunomide and switched,” reported Amit Bar-Or, MD, director of the Center of Neuroinflammation and Neurotherapeutics, University of Pennsylvania, Philadelphia.
Stated differently, if ofatumumab is delayed, it never fully compensates for the advantage of better early MS control in treatment-naïve patients, according to Dr. Bar-Or, who presented these data at the 2024 ECTRIMS annual meeting.
Anti-CD20 Disability Protection Already Seen in Pivotal Trial
In two phase 3 trials called ASCLEPIOS I and II that were published together several years ago in The New England Journal of Medicine, the anti-CD20 monoclonal antibody ofatumumab reduced the annualized relapse rate (ARR) by half (0.11 vs. 0.22). While ARR was the primary endpoint, ofatumumab was also associated with a 34% reduction (P = .002) in risk of confirmed disability worsening at 3 months (3mCDW) at a medium follow-up of 1.6 years.
After the completion of ASCLEPIOS I and II, the majority of both arms of the study were enrolled in the ALITHIOS extension study. Patients in ofatumumab arm have remained on their initially assigned drug. Patients in the teriflunomide group were switched. Characterized as the delayed ofatumumab group, they have been receiving the same 20-mg, once-monthly subcutaneous (SQ) dose of ofatumumab as those initially assigned to this drug. ALITHIOS will continue to follow both groups until 2028.
Patients have now been followed for up to 6 years. In the latest results presented at ECTRIMS, data were available for 690 patients on continuous treatment and 677 switch patients. Baseline characteristics of the two groups were similar. About half of each group were treatment naive when enrolled in the ASCLEPIOS trials.
Whether compared for 6-month confirmed disability worsening (6mCDW), 6-month progression independent of relapse activity (6mPIRA) or 6-month relapse-associated worsening (6mRAW), disease progression was consistently worse for those with delayed ofatumumab. The differences were most pronounced in those who were treatment naive when started on therapy.
Anti-CD20 MAB sustains Disability Protection for up to Years
For those who were treatment naive, the rates of 6mCDW at the most recent follow-up were 16.61% vs 23.74% (P = .033) for continuous and delayed ofatumumab, respectively. For the entire study, these rates were 21.09% versus 24.77%, respectively, which represented a strong trend (P = .063).
The relative rates for 6mPIRA (11.12% vs 16.75%) and 6mRAW (4.26% vs 4.82%) in treatment-naive patients also favored continuous over delayed ofatumumab, and the numerical advantage was also seen with up to 6 years of follow-up in the overall study population for 6mPIRA (15.45% vs 16.56%) and 6mRAW (5.24% vs 5.81%).
Translating these into freedom from disability, Dr. Bar-Or reported that more than 80% (83.4%) of patients on continuous ofatumumab were progression free for up to 6 years, a figure that exceeded the 76.3% free of progression in the delayed ofatumumab group.
On the basis of 6mPIRA, that absence of disability progression neared 90% (88.9%) on continuous ofatumumab relative to 83.3% for delayed ofatumumab.
An advantage for a reduction in disability accumulation for ofatumumab relative to teriflunomide was established at the end of the ASCLEPIOS I and II trial, but the latest follow-up shows that it is “sustained out to 6 years.” The advantage is achieved with no greater cost in adverse events during the early treatment period, according to Dr. Bar-Or, who noted that ofatumumab and teriflunomide were similarly well tolerated in ASCLEPIOS I and II.
No New Gd T1 Lesions Observed Over 12 Months
Although other anti-CD20 monoclonal antibodies have also been shown to be highly effective and often more effective than immunomodulators in the first- and second-line treatment of relapsing remitting MS (RRMS), another set of data presented at ECTRIMS 2024 looked specifically at transitioning from intravenous (IV) anti-CD20 drugs to SQ ofatumumab.
In this study, called OLIKOS, 102 RRMS patients who had received either IV ocrelizumab or IV rituximab were followed after transitioning to ofatumumab administered SQ with an autoinjector pen. The primary endpoint was the proportion of patients with no change or a reduction gadolinium-enhancing (Gd) T1 lesions over 12 months of follow-up.
“At month 12, 84 of 84 evaluable patients with evaluable MRI assessments met the primary endpoint,” reported the principal investigator Le Hua, MD, director of the Multiple Sclerosis Program, Cleveland Clinic in Ohio.
At 12 months, there were also no new or enlarging T2 lesions in 98% of patients receiving SQ ofatumumab following the transition from one of the other anti-CD20 IV drugs, but Dr. Hua characterized this as an exploratory endpoint.
The safety and tolerability data during the OLIKOS study was also reassuring with no new or unexpected safety signals for SQ ofatumumab, which has been well tolerated in the phase 3 development program. IgM and IgG levels remained stable over the course of follow-up.
High-efficacy anti-CD20 drugs were once reserved for RRMS patients with highly active disease, but long-term data, such as those generated by the ALITHIOS extension study, suggest greater efficacy with acceptable safety of these agents relative to conventional first-line RRMS therapies. Based on ALITHIOS data, Dr. Bar-Or suggested that early use of the most effective therapy appears to lead to better long-term protection from increased cumulative disability.
Dr. Bar-Or reported financial relationships with Accure, Atara, Biogen, Bristol-Myers Squibb, Celgene, GlaxoSmithKline, Gossamer, Janssen/Actelion, Medimmune, Merck/EMD Serono, Novartis, Roche/Genentech, and Sanofi-Genzyme. Dr. Hua reported financial relationships with Alexion, EMD Serono, Genentech, Horizon, Novartis, and TG Therapeutics.
FROM ECTRIMS 2024
Novel Agent First to Slow Disability in Nonrelapsing Secondary MS
COPENHAGEN — A new investigational drug has become the first agent to slow disability in patients with nonrelapsing secondary progressive multiple sclerosis (nrSPMS).
In addition, tolebrutinib almost doubled the number of patients who experienced confirmed disability improvement from 5% to 10%.
However, these benefits come with the potential safety issue of liver toxicity, with raised liver enzymes reported in 4% of patients and very severe liver enzyme rises occurring in 0.5% of patients, one of whom died after undergoing a liver transplant.
The results were presented by Robert Fox, MD, vice chair of research at the Cleveland Clinic’s Neurological Institute in Ohio, at the 2024 ECTRIMS annual meeting.
“We have finally found a therapy that can alter the compartmentalized inflammation that is driving progressive MS,” he said.
Dr. Fox pointed out that the population enrolled in the HERCULES trial had stopped having clinical relapses. “These are the patients for whom current immunomodulator therapies really don’t work at all — they don’t slow disability. This trial suggests that tolebrutinib can fill that void and now we have something to offer this patient group,” he said.
He estimated that up to 30% of patients with MS at his clinic may fall into this category.
A typical patient with nrSPMS who was included in this trial may have experienced a gradual decline in the distance they can walk or the ease with which they could climb stairs, he explained.
“I would project that this therapy will slow down that gradual decline, and, in some patients, it may actually stop the decline,” he added.
Dr. Fox said that BTK inhibitors are believed to have two main mechanisms of action relevant to MS — down-regulating B cells, probably mostly in the periphery, and, as these agents can cross the blood-brain barrier, they also appear to reduce the inflammatory activity of microglia and macrophages in the brain.
He noted that the disability progression in nrSPMS patients is thought to be caused by compartmentalized inflammation in the brain, which is what tolebrutinib may be targeting.
He noted that siponimod has also shown benefit in secondary progressive MS in the EXPAND trial, but the benefit was almost entirely restricted to patients who had experienced recent relapses.
Ocrelizumab has been shown to be beneficial in a trial in primary progressive MS, but again, a large proportion of patients in that study had active focal inflammation at baselineEngl J Med. 2017;376:209-220).
Trial Results
The HERCULES trial included 1131 patients with nrSPMS, defined as having an Expanded Disability Status Scale score (EDSS) between 3.0 and 6.5, no clinical relapses in the previous 24 months, and documented evidence of disability accumulation in the previous 12 months.
They were randomly assigned (2:1) to receive 60 mg tolebrutinib as an oral daily dose or placebo for up to approximately 48 months. This was an event-driven trial, with 288 6-month confirmed disability progression events required.
About 23% of patients in each group discontinued treatment and 12%-17% who had confirmed disability progression elected to crossover to open-label tolebrutinib.
The study population had an average age of 49 years, had a median EDSS score of 6, and a mean time since last clinical relapse of over 7 years.
“So, this was a really very quiescent patient population in terms of focal inflammation,” Dr. Fox noted.
Results showed that the primary endpoint showed a 31% reduction in the risk of 6-month confirmed disability progression (26.9% tolebrutinib vs. 37.2% placebo; hazard ratio [HR], 0.69; 95% CI, 0.55-0.88).
Rates of 3-month confirmed disability progression were 32.6% in the tolebrutinib group versus 41.5% with placebo — a 24% risk reduction.
In addition, 6-month confirmed disability improvement was achieved by 10% of tolebrutinib patients versus 5% in the placebo group (HR, 1.88; 95% CI, 1.10-3.21).
A ‘Head-scratcher’ Finding
Surprisingly, he noted, tolebrutinib did not appear to slow brain atrophy.
“Despite seeing a benefit on disability progression, we saw no significant slowing of brain atrophy or brain volume loss over the course of the study,” Dr. Fox reported.
He described this discordance between disability rates and brain volume loss rates as “a bit of a head-scratcher.”
In terms of safety, the main concern is liver enzyme elevations, which occurred at greater than three times the upper limit of normal (ULN) in 4.1% of the tolebrutinib group vs 1.6% in the placebo group.
A small (0.5%) proportion of patients treated with tolebrutinib experienced very severe elevations (> 20 x ULN) in liver enzymes, and one of these patients had to have a liver transplant and died because of postoperative complications, “a reminder that this can be a very serious complication of this drug,” said Dr. Fox.
However, he noted that all the very severe liver enzyme rises occurred in the first 3 months and it is now recommended that patients undergo weekly liver enzyme monitoring for the first 12 weeks of treatment.
Other adverse effects that were increased slightly in tolebrutinib group were upper respiratory infections and possibly hypertension.
Weekly Liver Enzyme Testing
Dr. Fox cautioned that patients starting tolebrutinib would need to undergo weekly liver enzyme testing in the first few months of treatment. “They would need to be very attentive to this monitoring, but if they are willing to do that, then I think many of these patients will be very eager to take this drug that may slow down their disability progression.”
The drug’s manufacturer, Sanofi, said the trial results will form the basis for applications to global regulatory authorities with submissions starting later in 2024.
Commenting on the trial, Ludwig Kappos, MD, professor of neurology at University Hospital and University of Basel, Switzerland, said the trial was important as it had shown “a robust effect on confirmed disability progression in a population of secondary progressive MS with no or very low signs of focal inflammation.”
“The effect is similar and probably more pronounced than that seen in the siponimod trial also in advanced secondary progressive MS,” he added.
Dr. Kappos believes more work will be needed to make sure the liver toxicity can be prevented, “but if that can be resolved then patients could have a significant delay in accumulating disability.”
GEMINI Trials Also Show Slowed Disability
Two other phase 3 trials of tolebrutinib were presented during the same ECTRIMS session — GEMINI 1 and 2 — which compared the new drug with teriflunomide, a standard of care treatment, in participants with relapsing MS. Neither study met the primary endpoint of an improvement in annualized relapse rates, compared with teriflunomide.
However, with respect to the key secondary endpoint, in a pooled analysis of data from GEMINI 1 and 2, tolebrutinib delayed the time to onset of 6-month confirmed disability worsening by 29%, a finding in line with the main results of the HERCULES trial.
“The significant impact of tolebrutinib on disability accumulation versus teriflunomide, in the absence of a statistically superior impact on relapses, also suggests that tolebrutinib may address smoldering neuroinflammation, which manifests as progression independent of relapses” Dr. Fox said.
The HERCULES trial was sponsored by Sanofi. Dr. Fox is a paid adviser to Sanofi. Dr. Kappos led the EXPAND trial of siponimod in SPMS.
A version of this article first appeared on Medscape.com.
COPENHAGEN — A new investigational drug has become the first agent to slow disability in patients with nonrelapsing secondary progressive multiple sclerosis (nrSPMS).
In addition, tolebrutinib almost doubled the number of patients who experienced confirmed disability improvement from 5% to 10%.
However, these benefits come with the potential safety issue of liver toxicity, with raised liver enzymes reported in 4% of patients and very severe liver enzyme rises occurring in 0.5% of patients, one of whom died after undergoing a liver transplant.
The results were presented by Robert Fox, MD, vice chair of research at the Cleveland Clinic’s Neurological Institute in Ohio, at the 2024 ECTRIMS annual meeting.
“We have finally found a therapy that can alter the compartmentalized inflammation that is driving progressive MS,” he said.
Dr. Fox pointed out that the population enrolled in the HERCULES trial had stopped having clinical relapses. “These are the patients for whom current immunomodulator therapies really don’t work at all — they don’t slow disability. This trial suggests that tolebrutinib can fill that void and now we have something to offer this patient group,” he said.
He estimated that up to 30% of patients with MS at his clinic may fall into this category.
A typical patient with nrSPMS who was included in this trial may have experienced a gradual decline in the distance they can walk or the ease with which they could climb stairs, he explained.
“I would project that this therapy will slow down that gradual decline, and, in some patients, it may actually stop the decline,” he added.
Dr. Fox said that BTK inhibitors are believed to have two main mechanisms of action relevant to MS — down-regulating B cells, probably mostly in the periphery, and, as these agents can cross the blood-brain barrier, they also appear to reduce the inflammatory activity of microglia and macrophages in the brain.
He noted that the disability progression in nrSPMS patients is thought to be caused by compartmentalized inflammation in the brain, which is what tolebrutinib may be targeting.
He noted that siponimod has also shown benefit in secondary progressive MS in the EXPAND trial, but the benefit was almost entirely restricted to patients who had experienced recent relapses.
Ocrelizumab has been shown to be beneficial in a trial in primary progressive MS, but again, a large proportion of patients in that study had active focal inflammation at baselineEngl J Med. 2017;376:209-220).
Trial Results
The HERCULES trial included 1131 patients with nrSPMS, defined as having an Expanded Disability Status Scale score (EDSS) between 3.0 and 6.5, no clinical relapses in the previous 24 months, and documented evidence of disability accumulation in the previous 12 months.
They were randomly assigned (2:1) to receive 60 mg tolebrutinib as an oral daily dose or placebo for up to approximately 48 months. This was an event-driven trial, with 288 6-month confirmed disability progression events required.
About 23% of patients in each group discontinued treatment and 12%-17% who had confirmed disability progression elected to crossover to open-label tolebrutinib.
The study population had an average age of 49 years, had a median EDSS score of 6, and a mean time since last clinical relapse of over 7 years.
“So, this was a really very quiescent patient population in terms of focal inflammation,” Dr. Fox noted.
Results showed that the primary endpoint showed a 31% reduction in the risk of 6-month confirmed disability progression (26.9% tolebrutinib vs. 37.2% placebo; hazard ratio [HR], 0.69; 95% CI, 0.55-0.88).
Rates of 3-month confirmed disability progression were 32.6% in the tolebrutinib group versus 41.5% with placebo — a 24% risk reduction.
In addition, 6-month confirmed disability improvement was achieved by 10% of tolebrutinib patients versus 5% in the placebo group (HR, 1.88; 95% CI, 1.10-3.21).
A ‘Head-scratcher’ Finding
Surprisingly, he noted, tolebrutinib did not appear to slow brain atrophy.
“Despite seeing a benefit on disability progression, we saw no significant slowing of brain atrophy or brain volume loss over the course of the study,” Dr. Fox reported.
He described this discordance between disability rates and brain volume loss rates as “a bit of a head-scratcher.”
In terms of safety, the main concern is liver enzyme elevations, which occurred at greater than three times the upper limit of normal (ULN) in 4.1% of the tolebrutinib group vs 1.6% in the placebo group.
A small (0.5%) proportion of patients treated with tolebrutinib experienced very severe elevations (> 20 x ULN) in liver enzymes, and one of these patients had to have a liver transplant and died because of postoperative complications, “a reminder that this can be a very serious complication of this drug,” said Dr. Fox.
However, he noted that all the very severe liver enzyme rises occurred in the first 3 months and it is now recommended that patients undergo weekly liver enzyme monitoring for the first 12 weeks of treatment.
Other adverse effects that were increased slightly in tolebrutinib group were upper respiratory infections and possibly hypertension.
Weekly Liver Enzyme Testing
Dr. Fox cautioned that patients starting tolebrutinib would need to undergo weekly liver enzyme testing in the first few months of treatment. “They would need to be very attentive to this monitoring, but if they are willing to do that, then I think many of these patients will be very eager to take this drug that may slow down their disability progression.”
The drug’s manufacturer, Sanofi, said the trial results will form the basis for applications to global regulatory authorities with submissions starting later in 2024.
Commenting on the trial, Ludwig Kappos, MD, professor of neurology at University Hospital and University of Basel, Switzerland, said the trial was important as it had shown “a robust effect on confirmed disability progression in a population of secondary progressive MS with no or very low signs of focal inflammation.”
“The effect is similar and probably more pronounced than that seen in the siponimod trial also in advanced secondary progressive MS,” he added.
Dr. Kappos believes more work will be needed to make sure the liver toxicity can be prevented, “but if that can be resolved then patients could have a significant delay in accumulating disability.”
GEMINI Trials Also Show Slowed Disability
Two other phase 3 trials of tolebrutinib were presented during the same ECTRIMS session — GEMINI 1 and 2 — which compared the new drug with teriflunomide, a standard of care treatment, in participants with relapsing MS. Neither study met the primary endpoint of an improvement in annualized relapse rates, compared with teriflunomide.
However, with respect to the key secondary endpoint, in a pooled analysis of data from GEMINI 1 and 2, tolebrutinib delayed the time to onset of 6-month confirmed disability worsening by 29%, a finding in line with the main results of the HERCULES trial.
“The significant impact of tolebrutinib on disability accumulation versus teriflunomide, in the absence of a statistically superior impact on relapses, also suggests that tolebrutinib may address smoldering neuroinflammation, which manifests as progression independent of relapses” Dr. Fox said.
The HERCULES trial was sponsored by Sanofi. Dr. Fox is a paid adviser to Sanofi. Dr. Kappos led the EXPAND trial of siponimod in SPMS.
A version of this article first appeared on Medscape.com.
COPENHAGEN — A new investigational drug has become the first agent to slow disability in patients with nonrelapsing secondary progressive multiple sclerosis (nrSPMS).
In addition, tolebrutinib almost doubled the number of patients who experienced confirmed disability improvement from 5% to 10%.
However, these benefits come with the potential safety issue of liver toxicity, with raised liver enzymes reported in 4% of patients and very severe liver enzyme rises occurring in 0.5% of patients, one of whom died after undergoing a liver transplant.
The results were presented by Robert Fox, MD, vice chair of research at the Cleveland Clinic’s Neurological Institute in Ohio, at the 2024 ECTRIMS annual meeting.
“We have finally found a therapy that can alter the compartmentalized inflammation that is driving progressive MS,” he said.
Dr. Fox pointed out that the population enrolled in the HERCULES trial had stopped having clinical relapses. “These are the patients for whom current immunomodulator therapies really don’t work at all — they don’t slow disability. This trial suggests that tolebrutinib can fill that void and now we have something to offer this patient group,” he said.
He estimated that up to 30% of patients with MS at his clinic may fall into this category.
A typical patient with nrSPMS who was included in this trial may have experienced a gradual decline in the distance they can walk or the ease with which they could climb stairs, he explained.
“I would project that this therapy will slow down that gradual decline, and, in some patients, it may actually stop the decline,” he added.
Dr. Fox said that BTK inhibitors are believed to have two main mechanisms of action relevant to MS — down-regulating B cells, probably mostly in the periphery, and, as these agents can cross the blood-brain barrier, they also appear to reduce the inflammatory activity of microglia and macrophages in the brain.
He noted that the disability progression in nrSPMS patients is thought to be caused by compartmentalized inflammation in the brain, which is what tolebrutinib may be targeting.
He noted that siponimod has also shown benefit in secondary progressive MS in the EXPAND trial, but the benefit was almost entirely restricted to patients who had experienced recent relapses.
Ocrelizumab has been shown to be beneficial in a trial in primary progressive MS, but again, a large proportion of patients in that study had active focal inflammation at baselineEngl J Med. 2017;376:209-220).
Trial Results
The HERCULES trial included 1131 patients with nrSPMS, defined as having an Expanded Disability Status Scale score (EDSS) between 3.0 and 6.5, no clinical relapses in the previous 24 months, and documented evidence of disability accumulation in the previous 12 months.
They were randomly assigned (2:1) to receive 60 mg tolebrutinib as an oral daily dose or placebo for up to approximately 48 months. This was an event-driven trial, with 288 6-month confirmed disability progression events required.
About 23% of patients in each group discontinued treatment and 12%-17% who had confirmed disability progression elected to crossover to open-label tolebrutinib.
The study population had an average age of 49 years, had a median EDSS score of 6, and a mean time since last clinical relapse of over 7 years.
“So, this was a really very quiescent patient population in terms of focal inflammation,” Dr. Fox noted.
Results showed that the primary endpoint showed a 31% reduction in the risk of 6-month confirmed disability progression (26.9% tolebrutinib vs. 37.2% placebo; hazard ratio [HR], 0.69; 95% CI, 0.55-0.88).
Rates of 3-month confirmed disability progression were 32.6% in the tolebrutinib group versus 41.5% with placebo — a 24% risk reduction.
In addition, 6-month confirmed disability improvement was achieved by 10% of tolebrutinib patients versus 5% in the placebo group (HR, 1.88; 95% CI, 1.10-3.21).
A ‘Head-scratcher’ Finding
Surprisingly, he noted, tolebrutinib did not appear to slow brain atrophy.
“Despite seeing a benefit on disability progression, we saw no significant slowing of brain atrophy or brain volume loss over the course of the study,” Dr. Fox reported.
He described this discordance between disability rates and brain volume loss rates as “a bit of a head-scratcher.”
In terms of safety, the main concern is liver enzyme elevations, which occurred at greater than three times the upper limit of normal (ULN) in 4.1% of the tolebrutinib group vs 1.6% in the placebo group.
A small (0.5%) proportion of patients treated with tolebrutinib experienced very severe elevations (> 20 x ULN) in liver enzymes, and one of these patients had to have a liver transplant and died because of postoperative complications, “a reminder that this can be a very serious complication of this drug,” said Dr. Fox.
However, he noted that all the very severe liver enzyme rises occurred in the first 3 months and it is now recommended that patients undergo weekly liver enzyme monitoring for the first 12 weeks of treatment.
Other adverse effects that were increased slightly in tolebrutinib group were upper respiratory infections and possibly hypertension.
Weekly Liver Enzyme Testing
Dr. Fox cautioned that patients starting tolebrutinib would need to undergo weekly liver enzyme testing in the first few months of treatment. “They would need to be very attentive to this monitoring, but if they are willing to do that, then I think many of these patients will be very eager to take this drug that may slow down their disability progression.”
The drug’s manufacturer, Sanofi, said the trial results will form the basis for applications to global regulatory authorities with submissions starting later in 2024.
Commenting on the trial, Ludwig Kappos, MD, professor of neurology at University Hospital and University of Basel, Switzerland, said the trial was important as it had shown “a robust effect on confirmed disability progression in a population of secondary progressive MS with no or very low signs of focal inflammation.”
“The effect is similar and probably more pronounced than that seen in the siponimod trial also in advanced secondary progressive MS,” he added.
Dr. Kappos believes more work will be needed to make sure the liver toxicity can be prevented, “but if that can be resolved then patients could have a significant delay in accumulating disability.”
GEMINI Trials Also Show Slowed Disability
Two other phase 3 trials of tolebrutinib were presented during the same ECTRIMS session — GEMINI 1 and 2 — which compared the new drug with teriflunomide, a standard of care treatment, in participants with relapsing MS. Neither study met the primary endpoint of an improvement in annualized relapse rates, compared with teriflunomide.
However, with respect to the key secondary endpoint, in a pooled analysis of data from GEMINI 1 and 2, tolebrutinib delayed the time to onset of 6-month confirmed disability worsening by 29%, a finding in line with the main results of the HERCULES trial.
“The significant impact of tolebrutinib on disability accumulation versus teriflunomide, in the absence of a statistically superior impact on relapses, also suggests that tolebrutinib may address smoldering neuroinflammation, which manifests as progression independent of relapses” Dr. Fox said.
The HERCULES trial was sponsored by Sanofi. Dr. Fox is a paid adviser to Sanofi. Dr. Kappos led the EXPAND trial of siponimod in SPMS.
A version of this article first appeared on Medscape.com.
FROM ECTRIMS 2024
No Signal of Benefit for Simvastatin in Progressive MS
COPENHAGEN — There were high hopes that simvastatin, a well-tolerated lipid-lowering therapy, would reduce disability progression in patients with nonflaring secondary progressive multiple sclerosis (SPMS), but a definitive multicenter double-blind randomized trial found no benefit at all.
“There was no effect on the primary outcome of confirmed progression or on any of the secondary outcomes,” reported Jeremy Chataway, MD, PhD, consultant neurologist, National Hospital for Neurology and Neurosurgery, University College of London, England.
For the primary outcome of progression on the Expanded Disability Status Scale (EDSS), the nonsignificant hazard ratio (HR) was, in fact, in favor of placebo (HR, 1.13; P = .26) over 45 months of follow-up and 365 progression events.
No Meaningful Difference Between Study Arms
“There were wide confidence intervals [95% CI, 0.91-1.39], so, really, there were no differences between the two arms,” reported Dr. Chataway, who presented the simvastatin trial, called MS-STAT2, during the late-breaker session of the 2024 ECTRIMS annual meeting.
Over a period of more than 20 years, a series of experimental and clinical studies have indicated that simvastatin and other CoA reductase inhibitors have anti-inflammatory and neuroprotective effects. These studies were the basis for the first MED-STAT study, which was a placebo-controlled randomized trial published in 2014.
Although this study did not have a clinical endpoint, it associated simvastatin with a 43% reduction (P = .003) in the annualized rate of brain atrophy, which has been widely accepted as a surrogate measure of MS progression.
In MS-STAT2, 964 patients were available for the intention-to-treat analysis. An established diagnosis of SPMS, an age of 25-65, and an EDSS score of 4.0-6.5 were among the inclusion criteria. Patients were required to be relapse-free for at least 3 months prior to study entry.
Importantly, patients were excluded if they were taking statin-lowering therapies or were candidates for these therapies due to the presence of cardiovascular disease. They were also excluded from entering the trial if taking immunosuppressants, such as methotrexate or azathioprine, or had exposure to monoclonal antibodies employed in the treatment of MS, such as natalizumab and alemtuzumab, in the prior 12 months.
Randomized to 80 mg of simvastatin (40 mg in the first month followed by rapid upward titration) or placebo in a 1:1 fashion, patients remained on their assigned therapy for 3 years in the absence of progression. At the end of this time, patients who remained progression-free could continue for up to 45 months while still blinded to treatment assignment.
Even though a large proportion of patients who were eligible to remain in the study for the full 45 months did so, the retention did not reflect clinical improvement.
Indeed, the secondary endpoints also produced no signal of benefit. On a composite secondary endpoint of EDSS, ambulation in the form of the 25-foot walk, and upper extremity function in the form of the 9-hole peg test (9-HPT), the numerical odds ratio (OR) went in the wrong direction for simvastatin although the difference was not significant (OR, 1.17; P = .26).
Annualized Relapse Rate Numerically Higher on Simvastatin
The annualized relapse rate, another secondary endpoint, was low in both arms of the study at 0.05 relapses/year for placebo and 0.7 relapses/year for simvastatin. Again, this result, although numerically unfavorable for simvastatin did not reach statistical significance (OR, 1.43; P = .04).
Simvastatin had a placebo-like safety profile. The single case of rhabdomyolysis in the simvastatin arm, which occurred early after randomization, resolved. Otherwise, simvastatin was well tolerated.
Conducted before and through the period of the COVID-19 pandemic, the number of progression events tripled in the year after the COVID-19 pandemic started relative to the prior year. At the end of the pandemic, progression events returned to a level similar to that before its onset. However, although Dr. Chataway noted this was an interesting example of comorbidities exacerbating MS, he emphasized that this increase was similar in the simvastatin and placebo arms.
There are more analyses to come, including patient-reported outcomes, biomarker analyses, and further comparisons of change in MRIs, but Dr. Chataway acknowledged that the study provided no support for the underlying hypothesis.
Several experts commenting after the study was presented, including Ludwig Kappos, MD, PhD, Chair of Neurology at the University Hospital, Basel, Switzerland, agreed.
“Unfortunately, these results are quite disappointing,” he said. When asked if there is any rationale for further pursuing studies of simvastatin for the treatment of SPMS, he said no.
“These data are quite convincing that there is no benefit. I do not see where you could go from here,” Dr. Kappos said in an interview.
Dr. Chataway, asked the same question, reiterated that there are a number of preplanned analyses that will be completed, but he does not foresee further studies with simvastatin for the indication studied in MS-STAT-2 trial.
However, he also emphasized strongly that simvastatin or any other lipid-lowering therapy should not be withheld from MS patients that need these drugs for a cardiovascular indication.
“We saw no benefit seen from simvastatin for patients with stable SPMS, but these drugs were well tolerated and they can be life-saving therapies for patients with increased cardiovascular risk,” Dr. Chataway said.
Dr, Chataway reported financial relationships with Biogen, Genzyme, Ionis, Lucid, Merck NerveGen, Novartis, Roche, and Sanofi. Dr. Kappos reports financial relationships with more than 20 pharmaceutical companies. The MS-STAT2 trial received no funding from industry.
COPENHAGEN — There were high hopes that simvastatin, a well-tolerated lipid-lowering therapy, would reduce disability progression in patients with nonflaring secondary progressive multiple sclerosis (SPMS), but a definitive multicenter double-blind randomized trial found no benefit at all.
“There was no effect on the primary outcome of confirmed progression or on any of the secondary outcomes,” reported Jeremy Chataway, MD, PhD, consultant neurologist, National Hospital for Neurology and Neurosurgery, University College of London, England.
For the primary outcome of progression on the Expanded Disability Status Scale (EDSS), the nonsignificant hazard ratio (HR) was, in fact, in favor of placebo (HR, 1.13; P = .26) over 45 months of follow-up and 365 progression events.
No Meaningful Difference Between Study Arms
“There were wide confidence intervals [95% CI, 0.91-1.39], so, really, there were no differences between the two arms,” reported Dr. Chataway, who presented the simvastatin trial, called MS-STAT2, during the late-breaker session of the 2024 ECTRIMS annual meeting.
Over a period of more than 20 years, a series of experimental and clinical studies have indicated that simvastatin and other CoA reductase inhibitors have anti-inflammatory and neuroprotective effects. These studies were the basis for the first MED-STAT study, which was a placebo-controlled randomized trial published in 2014.
Although this study did not have a clinical endpoint, it associated simvastatin with a 43% reduction (P = .003) in the annualized rate of brain atrophy, which has been widely accepted as a surrogate measure of MS progression.
In MS-STAT2, 964 patients were available for the intention-to-treat analysis. An established diagnosis of SPMS, an age of 25-65, and an EDSS score of 4.0-6.5 were among the inclusion criteria. Patients were required to be relapse-free for at least 3 months prior to study entry.
Importantly, patients were excluded if they were taking statin-lowering therapies or were candidates for these therapies due to the presence of cardiovascular disease. They were also excluded from entering the trial if taking immunosuppressants, such as methotrexate or azathioprine, or had exposure to monoclonal antibodies employed in the treatment of MS, such as natalizumab and alemtuzumab, in the prior 12 months.
Randomized to 80 mg of simvastatin (40 mg in the first month followed by rapid upward titration) or placebo in a 1:1 fashion, patients remained on their assigned therapy for 3 years in the absence of progression. At the end of this time, patients who remained progression-free could continue for up to 45 months while still blinded to treatment assignment.
Even though a large proportion of patients who were eligible to remain in the study for the full 45 months did so, the retention did not reflect clinical improvement.
Indeed, the secondary endpoints also produced no signal of benefit. On a composite secondary endpoint of EDSS, ambulation in the form of the 25-foot walk, and upper extremity function in the form of the 9-hole peg test (9-HPT), the numerical odds ratio (OR) went in the wrong direction for simvastatin although the difference was not significant (OR, 1.17; P = .26).
Annualized Relapse Rate Numerically Higher on Simvastatin
The annualized relapse rate, another secondary endpoint, was low in both arms of the study at 0.05 relapses/year for placebo and 0.7 relapses/year for simvastatin. Again, this result, although numerically unfavorable for simvastatin did not reach statistical significance (OR, 1.43; P = .04).
Simvastatin had a placebo-like safety profile. The single case of rhabdomyolysis in the simvastatin arm, which occurred early after randomization, resolved. Otherwise, simvastatin was well tolerated.
Conducted before and through the period of the COVID-19 pandemic, the number of progression events tripled in the year after the COVID-19 pandemic started relative to the prior year. At the end of the pandemic, progression events returned to a level similar to that before its onset. However, although Dr. Chataway noted this was an interesting example of comorbidities exacerbating MS, he emphasized that this increase was similar in the simvastatin and placebo arms.
There are more analyses to come, including patient-reported outcomes, biomarker analyses, and further comparisons of change in MRIs, but Dr. Chataway acknowledged that the study provided no support for the underlying hypothesis.
Several experts commenting after the study was presented, including Ludwig Kappos, MD, PhD, Chair of Neurology at the University Hospital, Basel, Switzerland, agreed.
“Unfortunately, these results are quite disappointing,” he said. When asked if there is any rationale for further pursuing studies of simvastatin for the treatment of SPMS, he said no.
“These data are quite convincing that there is no benefit. I do not see where you could go from here,” Dr. Kappos said in an interview.
Dr. Chataway, asked the same question, reiterated that there are a number of preplanned analyses that will be completed, but he does not foresee further studies with simvastatin for the indication studied in MS-STAT-2 trial.
However, he also emphasized strongly that simvastatin or any other lipid-lowering therapy should not be withheld from MS patients that need these drugs for a cardiovascular indication.
“We saw no benefit seen from simvastatin for patients with stable SPMS, but these drugs were well tolerated and they can be life-saving therapies for patients with increased cardiovascular risk,” Dr. Chataway said.
Dr, Chataway reported financial relationships with Biogen, Genzyme, Ionis, Lucid, Merck NerveGen, Novartis, Roche, and Sanofi. Dr. Kappos reports financial relationships with more than 20 pharmaceutical companies. The MS-STAT2 trial received no funding from industry.
COPENHAGEN — There were high hopes that simvastatin, a well-tolerated lipid-lowering therapy, would reduce disability progression in patients with nonflaring secondary progressive multiple sclerosis (SPMS), but a definitive multicenter double-blind randomized trial found no benefit at all.
“There was no effect on the primary outcome of confirmed progression or on any of the secondary outcomes,” reported Jeremy Chataway, MD, PhD, consultant neurologist, National Hospital for Neurology and Neurosurgery, University College of London, England.
For the primary outcome of progression on the Expanded Disability Status Scale (EDSS), the nonsignificant hazard ratio (HR) was, in fact, in favor of placebo (HR, 1.13; P = .26) over 45 months of follow-up and 365 progression events.
No Meaningful Difference Between Study Arms
“There were wide confidence intervals [95% CI, 0.91-1.39], so, really, there were no differences between the two arms,” reported Dr. Chataway, who presented the simvastatin trial, called MS-STAT2, during the late-breaker session of the 2024 ECTRIMS annual meeting.
Over a period of more than 20 years, a series of experimental and clinical studies have indicated that simvastatin and other CoA reductase inhibitors have anti-inflammatory and neuroprotective effects. These studies were the basis for the first MED-STAT study, which was a placebo-controlled randomized trial published in 2014.
Although this study did not have a clinical endpoint, it associated simvastatin with a 43% reduction (P = .003) in the annualized rate of brain atrophy, which has been widely accepted as a surrogate measure of MS progression.
In MS-STAT2, 964 patients were available for the intention-to-treat analysis. An established diagnosis of SPMS, an age of 25-65, and an EDSS score of 4.0-6.5 were among the inclusion criteria. Patients were required to be relapse-free for at least 3 months prior to study entry.
Importantly, patients were excluded if they were taking statin-lowering therapies or were candidates for these therapies due to the presence of cardiovascular disease. They were also excluded from entering the trial if taking immunosuppressants, such as methotrexate or azathioprine, or had exposure to monoclonal antibodies employed in the treatment of MS, such as natalizumab and alemtuzumab, in the prior 12 months.
Randomized to 80 mg of simvastatin (40 mg in the first month followed by rapid upward titration) or placebo in a 1:1 fashion, patients remained on their assigned therapy for 3 years in the absence of progression. At the end of this time, patients who remained progression-free could continue for up to 45 months while still blinded to treatment assignment.
Even though a large proportion of patients who were eligible to remain in the study for the full 45 months did so, the retention did not reflect clinical improvement.
Indeed, the secondary endpoints also produced no signal of benefit. On a composite secondary endpoint of EDSS, ambulation in the form of the 25-foot walk, and upper extremity function in the form of the 9-hole peg test (9-HPT), the numerical odds ratio (OR) went in the wrong direction for simvastatin although the difference was not significant (OR, 1.17; P = .26).
Annualized Relapse Rate Numerically Higher on Simvastatin
The annualized relapse rate, another secondary endpoint, was low in both arms of the study at 0.05 relapses/year for placebo and 0.7 relapses/year for simvastatin. Again, this result, although numerically unfavorable for simvastatin did not reach statistical significance (OR, 1.43; P = .04).
Simvastatin had a placebo-like safety profile. The single case of rhabdomyolysis in the simvastatin arm, which occurred early after randomization, resolved. Otherwise, simvastatin was well tolerated.
Conducted before and through the period of the COVID-19 pandemic, the number of progression events tripled in the year after the COVID-19 pandemic started relative to the prior year. At the end of the pandemic, progression events returned to a level similar to that before its onset. However, although Dr. Chataway noted this was an interesting example of comorbidities exacerbating MS, he emphasized that this increase was similar in the simvastatin and placebo arms.
There are more analyses to come, including patient-reported outcomes, biomarker analyses, and further comparisons of change in MRIs, but Dr. Chataway acknowledged that the study provided no support for the underlying hypothesis.
Several experts commenting after the study was presented, including Ludwig Kappos, MD, PhD, Chair of Neurology at the University Hospital, Basel, Switzerland, agreed.
“Unfortunately, these results are quite disappointing,” he said. When asked if there is any rationale for further pursuing studies of simvastatin for the treatment of SPMS, he said no.
“These data are quite convincing that there is no benefit. I do not see where you could go from here,” Dr. Kappos said in an interview.
Dr. Chataway, asked the same question, reiterated that there are a number of preplanned analyses that will be completed, but he does not foresee further studies with simvastatin for the indication studied in MS-STAT-2 trial.
However, he also emphasized strongly that simvastatin or any other lipid-lowering therapy should not be withheld from MS patients that need these drugs for a cardiovascular indication.
“We saw no benefit seen from simvastatin for patients with stable SPMS, but these drugs were well tolerated and they can be life-saving therapies for patients with increased cardiovascular risk,” Dr. Chataway said.
Dr, Chataway reported financial relationships with Biogen, Genzyme, Ionis, Lucid, Merck NerveGen, Novartis, Roche, and Sanofi. Dr. Kappos reports financial relationships with more than 20 pharmaceutical companies. The MS-STAT2 trial received no funding from industry.
FROM ECTRIMS 2024
Disability Reduction Is a Twist in Negative BTKi RRMS Trial
COPENHAGEN — In two phase 3 head-to-head comparing the Bruton tyrosine kinase inhibitor (BTKi) tolebrutinib to the immunomodulatory teriflunomide for relapsing-remitting multiple sclerosis (RRMS), there was no advantage on the primary endpoint of relapse, but the greater protection against disability, a secondary endpoint, might change thinking about BTKis as a potential MS therapy.
For annualized relapse rate (ARR), which is the basis on which these two drugs were compared, “there was no difference between tolebrutinib and teriflunomide,” reported Jiwon Oh, MD, Medical Director, Barlo Multiple Sclerosis Program, St. Michael’s Hospital, University of Toronto, Canada.
In the similar GEMINI 1 and 2 trials, the ARRs were nearly identical in the first, (0.13 and 0.12), and completely identical in the second (0.11) for tolebrutinib and teriflunomide, respectively.
Although Negative, GEMINI Trials Offer Intriguing Data
These data rule out the study hypothesis that a BTKi offers greater protection against relapse than a commonly used immunomodulator, but Dr. Oh suggested the study is still potentially relevant to MS research.
“There is hope,” Dr. Oh said, when reporting the findings of the GEMINI I and II trials during the latebreaker session at the 2024 ECTRIMS annual meeting. Ultimately, a substantial part of this hope was derived from the consistency of the GEMINI data with the placebo-controlled HERCULES trial of tolebrutinib presented immediately afterwards, but the disparity between the primary and secondary outcomes of GEMINI are, by themselves, relevant, suggesting that targets of treatment change as MS progresses from an acute to a chronic inflammatory process.
BTKi Associated With Reduced Disability
At 3 months, the rate of confirmed disability worsening (CDW) in the pooled GEMINI trials was 18.5% and 14.7% for tolebrutinib and teriflunomide, respectively, producing at 27% reduction in hazard ratio (HR) for this outcome (HR 0.73; P = .0018). At 6 months, the protection against disability (13.2% vs. 9.9%) persisted for tolebrutinib relative to teriflunomide (HR 0.71; P = .023).*
For the outcome of a confirmed disability improvement at 6 months, the higher rate in the tolebrutinib arm did not reach statistical significance (12.8% vs. 12.0%), but it did suggest a favorable trend (HR 1.22; P = .17).
While Dr. Oh acknowledged that secondary outcomes can only be considered hypothesis generating when the primary outcome is negative, she said these outcomes provide intriguing support for the potential of this BTKi drug to inhibit “smoldering inflammation.” Even if tolebrutinib was no more effective than teriflunomide against the acute inflammation that drives relapse, the GEMINI trials data support greater inhibition of the chronic inflammation implicated in progression in the absence of flares.
On MRI, the annualized rate of new and enlarging T2 lesions, although numerically higher in the tolebrutinib group, did not differ significantly in either GEMINI 1 (5.6 vs. 5.2; P = .46) or GEMINI 2 (5.1 vs. 4.4; P = .24). The least mean square difference in brain volume at end of study relative to 6 months into the study was 0.2% less in the tolebrutinib arm than the teriflunomide arm (P = .0002) in GEMINI 1, but the 0.04 numerical advantage for tolebrutinib did not reach statistical significance in GEMINI 2 (P = .43).
Of the 974 patients randomized in GEMINI 1 and 899 randomized in GEMINI 2, about 85% completed the 3-year trial. Almost all had RRMS (99%) rather than progressing MS. The median age was approximately 36 years, the baseline EDSS score was approximately 1.2, and the median time since diagnosis was about 6.5 years. The mean number of relapses in the prior year was approximately 0.6.
In GEMINI, the secondary outcomes foreshadowed the positive findings in the phase 3 HERCULES trial that came immediately after Dr. Oh’s GEMINI trials presentation. The HERCULES trial associated tolebrutinib with a 31% reduction in the risk of confirmed disability progression (CDW) relative to placebo in patients with non-relapsing secondary progressive MS (nrSPMS).
In HERCULES, 1172 patients with nrSPMS were randomized in a 2:1 fashion to tolebrutinib or placebo. For the primary endpoint of CDW at 6 months, tolebrutinib demonstrated a major and highly significant reduction in this primary endpoint (HR 0.69; P = .00026).
BTKi Disability Protection Supported By Progressive MS Trial
“This is the first trial to show significant slowing of disability in people with nrSPMS,” reported the principal investigator Robert J. Fox, MD, Vice Chair of the Neurological Institute at Cleveland Clinic, Cleveland, Ohio.
For disability improvement at 6 months, tolebrutinib was associated with a nearly 2-fold improvement (HR 1.88; P = .021). According to both Dr. Oh and Dr. Fox the results of these two major phase 3 tolebrutinib studies support the principle that the BTKi, which was shown to offer inhibition of relapse comparable to teriflunomide in the GEMINI trials, offers a greater inhibition of chronic inflammation.
“These results are consistent with the hypothesis that acute focal inflammation and smoldering neuroinflammation are two distinct biological processes,” Dr. Oh said.
Dr. Fox said that the HERCULES results will be submitted to regulatory authorities with the goal of securing an indication for tolebrutinib for nrSPMS.
Both Dr. Oh and Dr. Fox suggested these results are likely to reorient thinking about the pathophysiology of MS progression and how different processes can be targeted in the future. Other experts agreed.
“I think we are starting to look at different endpoints than ARR, particularly at those that might better reflect progression in later stages of MS and that are independent of ARR,” said Dalia Rotstein, MD, MS researcher and an assistant professor of neurology, University of Toronto, Canada.
A moderator of the ECTRIMS latebreaker session, she suggested that the differences between outcomes of the GEMINI trials and HERCULES trials might have relevance to each other even if the GEMINI trials did not meet their primary endpoint.
Dr. Oh reported financial relationships with Amgen, Biogen, Eli Lilly, EMD Serono, Novartis, Roche, and Sanofi, which provided funding for the GEMINI trials. Dr. Fox reported financial relationships with more than 15 pharmaceutical companies, including Sanofi, which also provided funding for the HERCULES trial. Dr. Rotstein reported financial relationships with Alexion, Biogen, EMD Serono, Horizon, Novartis, Roche, Sanofi, and Touch IME.
*Correction, 9/26/24: A previous version of this article contained an incorrect P value.
COPENHAGEN — In two phase 3 head-to-head comparing the Bruton tyrosine kinase inhibitor (BTKi) tolebrutinib to the immunomodulatory teriflunomide for relapsing-remitting multiple sclerosis (RRMS), there was no advantage on the primary endpoint of relapse, but the greater protection against disability, a secondary endpoint, might change thinking about BTKis as a potential MS therapy.
For annualized relapse rate (ARR), which is the basis on which these two drugs were compared, “there was no difference between tolebrutinib and teriflunomide,” reported Jiwon Oh, MD, Medical Director, Barlo Multiple Sclerosis Program, St. Michael’s Hospital, University of Toronto, Canada.
In the similar GEMINI 1 and 2 trials, the ARRs were nearly identical in the first, (0.13 and 0.12), and completely identical in the second (0.11) for tolebrutinib and teriflunomide, respectively.
Although Negative, GEMINI Trials Offer Intriguing Data
These data rule out the study hypothesis that a BTKi offers greater protection against relapse than a commonly used immunomodulator, but Dr. Oh suggested the study is still potentially relevant to MS research.
“There is hope,” Dr. Oh said, when reporting the findings of the GEMINI I and II trials during the latebreaker session at the 2024 ECTRIMS annual meeting. Ultimately, a substantial part of this hope was derived from the consistency of the GEMINI data with the placebo-controlled HERCULES trial of tolebrutinib presented immediately afterwards, but the disparity between the primary and secondary outcomes of GEMINI are, by themselves, relevant, suggesting that targets of treatment change as MS progresses from an acute to a chronic inflammatory process.
BTKi Associated With Reduced Disability
At 3 months, the rate of confirmed disability worsening (CDW) in the pooled GEMINI trials was 18.5% and 14.7% for tolebrutinib and teriflunomide, respectively, producing at 27% reduction in hazard ratio (HR) for this outcome (HR 0.73; P = .0018). At 6 months, the protection against disability (13.2% vs. 9.9%) persisted for tolebrutinib relative to teriflunomide (HR 0.71; P = .023).*
For the outcome of a confirmed disability improvement at 6 months, the higher rate in the tolebrutinib arm did not reach statistical significance (12.8% vs. 12.0%), but it did suggest a favorable trend (HR 1.22; P = .17).
While Dr. Oh acknowledged that secondary outcomes can only be considered hypothesis generating when the primary outcome is negative, she said these outcomes provide intriguing support for the potential of this BTKi drug to inhibit “smoldering inflammation.” Even if tolebrutinib was no more effective than teriflunomide against the acute inflammation that drives relapse, the GEMINI trials data support greater inhibition of the chronic inflammation implicated in progression in the absence of flares.
On MRI, the annualized rate of new and enlarging T2 lesions, although numerically higher in the tolebrutinib group, did not differ significantly in either GEMINI 1 (5.6 vs. 5.2; P = .46) or GEMINI 2 (5.1 vs. 4.4; P = .24). The least mean square difference in brain volume at end of study relative to 6 months into the study was 0.2% less in the tolebrutinib arm than the teriflunomide arm (P = .0002) in GEMINI 1, but the 0.04 numerical advantage for tolebrutinib did not reach statistical significance in GEMINI 2 (P = .43).
Of the 974 patients randomized in GEMINI 1 and 899 randomized in GEMINI 2, about 85% completed the 3-year trial. Almost all had RRMS (99%) rather than progressing MS. The median age was approximately 36 years, the baseline EDSS score was approximately 1.2, and the median time since diagnosis was about 6.5 years. The mean number of relapses in the prior year was approximately 0.6.
In GEMINI, the secondary outcomes foreshadowed the positive findings in the phase 3 HERCULES trial that came immediately after Dr. Oh’s GEMINI trials presentation. The HERCULES trial associated tolebrutinib with a 31% reduction in the risk of confirmed disability progression (CDW) relative to placebo in patients with non-relapsing secondary progressive MS (nrSPMS).
In HERCULES, 1172 patients with nrSPMS were randomized in a 2:1 fashion to tolebrutinib or placebo. For the primary endpoint of CDW at 6 months, tolebrutinib demonstrated a major and highly significant reduction in this primary endpoint (HR 0.69; P = .00026).
BTKi Disability Protection Supported By Progressive MS Trial
“This is the first trial to show significant slowing of disability in people with nrSPMS,” reported the principal investigator Robert J. Fox, MD, Vice Chair of the Neurological Institute at Cleveland Clinic, Cleveland, Ohio.
For disability improvement at 6 months, tolebrutinib was associated with a nearly 2-fold improvement (HR 1.88; P = .021). According to both Dr. Oh and Dr. Fox the results of these two major phase 3 tolebrutinib studies support the principle that the BTKi, which was shown to offer inhibition of relapse comparable to teriflunomide in the GEMINI trials, offers a greater inhibition of chronic inflammation.
“These results are consistent with the hypothesis that acute focal inflammation and smoldering neuroinflammation are two distinct biological processes,” Dr. Oh said.
Dr. Fox said that the HERCULES results will be submitted to regulatory authorities with the goal of securing an indication for tolebrutinib for nrSPMS.
Both Dr. Oh and Dr. Fox suggested these results are likely to reorient thinking about the pathophysiology of MS progression and how different processes can be targeted in the future. Other experts agreed.
“I think we are starting to look at different endpoints than ARR, particularly at those that might better reflect progression in later stages of MS and that are independent of ARR,” said Dalia Rotstein, MD, MS researcher and an assistant professor of neurology, University of Toronto, Canada.
A moderator of the ECTRIMS latebreaker session, she suggested that the differences between outcomes of the GEMINI trials and HERCULES trials might have relevance to each other even if the GEMINI trials did not meet their primary endpoint.
Dr. Oh reported financial relationships with Amgen, Biogen, Eli Lilly, EMD Serono, Novartis, Roche, and Sanofi, which provided funding for the GEMINI trials. Dr. Fox reported financial relationships with more than 15 pharmaceutical companies, including Sanofi, which also provided funding for the HERCULES trial. Dr. Rotstein reported financial relationships with Alexion, Biogen, EMD Serono, Horizon, Novartis, Roche, Sanofi, and Touch IME.
*Correction, 9/26/24: A previous version of this article contained an incorrect P value.
COPENHAGEN — In two phase 3 head-to-head comparing the Bruton tyrosine kinase inhibitor (BTKi) tolebrutinib to the immunomodulatory teriflunomide for relapsing-remitting multiple sclerosis (RRMS), there was no advantage on the primary endpoint of relapse, but the greater protection against disability, a secondary endpoint, might change thinking about BTKis as a potential MS therapy.
For annualized relapse rate (ARR), which is the basis on which these two drugs were compared, “there was no difference between tolebrutinib and teriflunomide,” reported Jiwon Oh, MD, Medical Director, Barlo Multiple Sclerosis Program, St. Michael’s Hospital, University of Toronto, Canada.
In the similar GEMINI 1 and 2 trials, the ARRs were nearly identical in the first, (0.13 and 0.12), and completely identical in the second (0.11) for tolebrutinib and teriflunomide, respectively.
Although Negative, GEMINI Trials Offer Intriguing Data
These data rule out the study hypothesis that a BTKi offers greater protection against relapse than a commonly used immunomodulator, but Dr. Oh suggested the study is still potentially relevant to MS research.
“There is hope,” Dr. Oh said, when reporting the findings of the GEMINI I and II trials during the latebreaker session at the 2024 ECTRIMS annual meeting. Ultimately, a substantial part of this hope was derived from the consistency of the GEMINI data with the placebo-controlled HERCULES trial of tolebrutinib presented immediately afterwards, but the disparity between the primary and secondary outcomes of GEMINI are, by themselves, relevant, suggesting that targets of treatment change as MS progresses from an acute to a chronic inflammatory process.
BTKi Associated With Reduced Disability
At 3 months, the rate of confirmed disability worsening (CDW) in the pooled GEMINI trials was 18.5% and 14.7% for tolebrutinib and teriflunomide, respectively, producing at 27% reduction in hazard ratio (HR) for this outcome (HR 0.73; P = .0018). At 6 months, the protection against disability (13.2% vs. 9.9%) persisted for tolebrutinib relative to teriflunomide (HR 0.71; P = .023).*
For the outcome of a confirmed disability improvement at 6 months, the higher rate in the tolebrutinib arm did not reach statistical significance (12.8% vs. 12.0%), but it did suggest a favorable trend (HR 1.22; P = .17).
While Dr. Oh acknowledged that secondary outcomes can only be considered hypothesis generating when the primary outcome is negative, she said these outcomes provide intriguing support for the potential of this BTKi drug to inhibit “smoldering inflammation.” Even if tolebrutinib was no more effective than teriflunomide against the acute inflammation that drives relapse, the GEMINI trials data support greater inhibition of the chronic inflammation implicated in progression in the absence of flares.
On MRI, the annualized rate of new and enlarging T2 lesions, although numerically higher in the tolebrutinib group, did not differ significantly in either GEMINI 1 (5.6 vs. 5.2; P = .46) or GEMINI 2 (5.1 vs. 4.4; P = .24). The least mean square difference in brain volume at end of study relative to 6 months into the study was 0.2% less in the tolebrutinib arm than the teriflunomide arm (P = .0002) in GEMINI 1, but the 0.04 numerical advantage for tolebrutinib did not reach statistical significance in GEMINI 2 (P = .43).
Of the 974 patients randomized in GEMINI 1 and 899 randomized in GEMINI 2, about 85% completed the 3-year trial. Almost all had RRMS (99%) rather than progressing MS. The median age was approximately 36 years, the baseline EDSS score was approximately 1.2, and the median time since diagnosis was about 6.5 years. The mean number of relapses in the prior year was approximately 0.6.
In GEMINI, the secondary outcomes foreshadowed the positive findings in the phase 3 HERCULES trial that came immediately after Dr. Oh’s GEMINI trials presentation. The HERCULES trial associated tolebrutinib with a 31% reduction in the risk of confirmed disability progression (CDW) relative to placebo in patients with non-relapsing secondary progressive MS (nrSPMS).
In HERCULES, 1172 patients with nrSPMS were randomized in a 2:1 fashion to tolebrutinib or placebo. For the primary endpoint of CDW at 6 months, tolebrutinib demonstrated a major and highly significant reduction in this primary endpoint (HR 0.69; P = .00026).
BTKi Disability Protection Supported By Progressive MS Trial
“This is the first trial to show significant slowing of disability in people with nrSPMS,” reported the principal investigator Robert J. Fox, MD, Vice Chair of the Neurological Institute at Cleveland Clinic, Cleveland, Ohio.
For disability improvement at 6 months, tolebrutinib was associated with a nearly 2-fold improvement (HR 1.88; P = .021). According to both Dr. Oh and Dr. Fox the results of these two major phase 3 tolebrutinib studies support the principle that the BTKi, which was shown to offer inhibition of relapse comparable to teriflunomide in the GEMINI trials, offers a greater inhibition of chronic inflammation.
“These results are consistent with the hypothesis that acute focal inflammation and smoldering neuroinflammation are two distinct biological processes,” Dr. Oh said.
Dr. Fox said that the HERCULES results will be submitted to regulatory authorities with the goal of securing an indication for tolebrutinib for nrSPMS.
Both Dr. Oh and Dr. Fox suggested these results are likely to reorient thinking about the pathophysiology of MS progression and how different processes can be targeted in the future. Other experts agreed.
“I think we are starting to look at different endpoints than ARR, particularly at those that might better reflect progression in later stages of MS and that are independent of ARR,” said Dalia Rotstein, MD, MS researcher and an assistant professor of neurology, University of Toronto, Canada.
A moderator of the ECTRIMS latebreaker session, she suggested that the differences between outcomes of the GEMINI trials and HERCULES trials might have relevance to each other even if the GEMINI trials did not meet their primary endpoint.
Dr. Oh reported financial relationships with Amgen, Biogen, Eli Lilly, EMD Serono, Novartis, Roche, and Sanofi, which provided funding for the GEMINI trials. Dr. Fox reported financial relationships with more than 15 pharmaceutical companies, including Sanofi, which also provided funding for the HERCULES trial. Dr. Rotstein reported financial relationships with Alexion, Biogen, EMD Serono, Horizon, Novartis, Roche, Sanofi, and Touch IME.
*Correction, 9/26/24: A previous version of this article contained an incorrect P value.
FROM ECTRIMS 2024
High-Dose Vitamin D Linked to Lower Disease Activity in CIS
COPENHAGEN — , results of a randomized, controlled trial suggest. In addition, cholecalciferol had a favorable safety profile and was well tolerated.
“These data support high-dose vitamin D supplementation in early MS and make vitamin D the best candidate for add-on therapy evaluation in the therapeutic strategy for multiple sclerosis [MS],” said study author Eric Thouvenot, MD, PhD, University Hospital of Nimes, Neurology Department, Nimes, France.
The study was presented at the 2024 ECTRIMS annual meeting.
Vitamin D Supplementation Versus Placebo
Research shows vitamin D deficiency is a risk factor for MS. However, results of previous research investigating vitamin D supplementation in MS, with different regimens and durations, have been contradictory.
The current double-blind study included 303 adults newly diagnosed with CIS (within 90 days) and a serum 25-hydroxy vitamin D concentration of less than 100 nmol/L at baseline. Participants had a median age of 34 years, and 70% were women.
About one third of participants had optic neuritis, two thirds had oligoclonal bands from cerebrospinal fluid analysis, and the median Expanded Disability Status Scale (EDSS) score was 1.0. Of the total, 89% fulfilled 2017 McDonald criteria for the diagnosis of relapsing-remitting MS (RRMS).
Participants were randomly assigned to receive high-dose (100,000 international units) oral cholecalciferol or placebo every 2 weeks for 24 months. Participants had a clinical visit at 3, 6, 12, 18, and 24 months, and brain and spinal cord MRI with and without gadolinium at 3, 12, and 24 months.
The primary outcome was occurrence of disease activity — relapse, new or enlarging T2 lesions, and presence of contrast-enhancing lesions.
Significant Difference
During follow-up, 60.3% in the vitamin group showed evidence of disease activity versus 74.1% in the placebo group (hazard ratio [HR], 0.66; 95% CI, 0.50-0.87; P = .004). In addition, the median time to evidence of disease activity was 432 days in the vitamin D group versus 224 days in the placebo group (P = .003).
“As you can see, the difference is really, really significant,” said Dr. Thouvenot, referring to a Kaplan-Meier curve. He said he was somewhat surprised by the “very rapid” effect of vitamin D.
He noted that the 34% reduction in relative risk for disease activity is “similar to that of some published platform therapies for CIS patients.”
An analysis of the 247 patients who met 2017 McDonald criteria for RRMS at baseline showed the same results.
Secondary analyses showed no significant reduction in relapses and no significant differences for annual change in EDSS, quality of life, fatigue, anxiety, or depression.
Additional analyses showed the HR was unchanged after adjusting for known prognostic factors including age, sex, number of lesions (< 9 vs ≥ 9), EDSS score at baseline, and delay between CIS and treatment onset.
Results showed vitamin D3 supplementation was safe and well tolerated. Dr. Thouvenot noted that 95% of participants completed the trial, and none of the 33 severe adverse events in 30 patients suggested hypercalcemia or were related to the study drug.
These encouraging new data support further studies of high-dose vitamin D supplementation as an add-on therapy in early MS, said Dr. Thouvenot. He noted that animal models suggest vitamin D added to interferon beta has a synergistic effect on the immune system.
‘Fabulous’ Research
During a question-and-answer session, delegates praised the study, with some describing it as “fantastic” or “fabulous.”
Addressing a query about why this study succeeded in showing the benefits of vitamin D while numerous previous studies did not, Dr. Thouvenot said it may be due to the longer duration or a design that was better powered to show differences.
Asked if researchers examined vitamin D blood levels during the study, Dr. Thouvenot said these measures are “ongoing.”
Responding to a question of whether high-dose vitamin D could be a lifelong treatment, he referred again to the “excellent” safety of the intervention. Not only is it well tolerated, but vitamin D benefits bones and the risk for hypercalcemia is low except perhaps for patients with tuberculosis or sarcoidosis, he said.
“When you exclude those patients, the safety is huge, so I don’t know why we should stop it once it’s started.”
This study was funded in part by the French Ministry of Health. Dr. Thouvenot reported no relevant disclosures.
A version of this article first appeared on Medscape.com.
COPENHAGEN — , results of a randomized, controlled trial suggest. In addition, cholecalciferol had a favorable safety profile and was well tolerated.
“These data support high-dose vitamin D supplementation in early MS and make vitamin D the best candidate for add-on therapy evaluation in the therapeutic strategy for multiple sclerosis [MS],” said study author Eric Thouvenot, MD, PhD, University Hospital of Nimes, Neurology Department, Nimes, France.
The study was presented at the 2024 ECTRIMS annual meeting.
Vitamin D Supplementation Versus Placebo
Research shows vitamin D deficiency is a risk factor for MS. However, results of previous research investigating vitamin D supplementation in MS, with different regimens and durations, have been contradictory.
The current double-blind study included 303 adults newly diagnosed with CIS (within 90 days) and a serum 25-hydroxy vitamin D concentration of less than 100 nmol/L at baseline. Participants had a median age of 34 years, and 70% were women.
About one third of participants had optic neuritis, two thirds had oligoclonal bands from cerebrospinal fluid analysis, and the median Expanded Disability Status Scale (EDSS) score was 1.0. Of the total, 89% fulfilled 2017 McDonald criteria for the diagnosis of relapsing-remitting MS (RRMS).
Participants were randomly assigned to receive high-dose (100,000 international units) oral cholecalciferol or placebo every 2 weeks for 24 months. Participants had a clinical visit at 3, 6, 12, 18, and 24 months, and brain and spinal cord MRI with and without gadolinium at 3, 12, and 24 months.
The primary outcome was occurrence of disease activity — relapse, new or enlarging T2 lesions, and presence of contrast-enhancing lesions.
Significant Difference
During follow-up, 60.3% in the vitamin group showed evidence of disease activity versus 74.1% in the placebo group (hazard ratio [HR], 0.66; 95% CI, 0.50-0.87; P = .004). In addition, the median time to evidence of disease activity was 432 days in the vitamin D group versus 224 days in the placebo group (P = .003).
“As you can see, the difference is really, really significant,” said Dr. Thouvenot, referring to a Kaplan-Meier curve. He said he was somewhat surprised by the “very rapid” effect of vitamin D.
He noted that the 34% reduction in relative risk for disease activity is “similar to that of some published platform therapies for CIS patients.”
An analysis of the 247 patients who met 2017 McDonald criteria for RRMS at baseline showed the same results.
Secondary analyses showed no significant reduction in relapses and no significant differences for annual change in EDSS, quality of life, fatigue, anxiety, or depression.
Additional analyses showed the HR was unchanged after adjusting for known prognostic factors including age, sex, number of lesions (< 9 vs ≥ 9), EDSS score at baseline, and delay between CIS and treatment onset.
Results showed vitamin D3 supplementation was safe and well tolerated. Dr. Thouvenot noted that 95% of participants completed the trial, and none of the 33 severe adverse events in 30 patients suggested hypercalcemia or were related to the study drug.
These encouraging new data support further studies of high-dose vitamin D supplementation as an add-on therapy in early MS, said Dr. Thouvenot. He noted that animal models suggest vitamin D added to interferon beta has a synergistic effect on the immune system.
‘Fabulous’ Research
During a question-and-answer session, delegates praised the study, with some describing it as “fantastic” or “fabulous.”
Addressing a query about why this study succeeded in showing the benefits of vitamin D while numerous previous studies did not, Dr. Thouvenot said it may be due to the longer duration or a design that was better powered to show differences.
Asked if researchers examined vitamin D blood levels during the study, Dr. Thouvenot said these measures are “ongoing.”
Responding to a question of whether high-dose vitamin D could be a lifelong treatment, he referred again to the “excellent” safety of the intervention. Not only is it well tolerated, but vitamin D benefits bones and the risk for hypercalcemia is low except perhaps for patients with tuberculosis or sarcoidosis, he said.
“When you exclude those patients, the safety is huge, so I don’t know why we should stop it once it’s started.”
This study was funded in part by the French Ministry of Health. Dr. Thouvenot reported no relevant disclosures.
A version of this article first appeared on Medscape.com.
COPENHAGEN — , results of a randomized, controlled trial suggest. In addition, cholecalciferol had a favorable safety profile and was well tolerated.
“These data support high-dose vitamin D supplementation in early MS and make vitamin D the best candidate for add-on therapy evaluation in the therapeutic strategy for multiple sclerosis [MS],” said study author Eric Thouvenot, MD, PhD, University Hospital of Nimes, Neurology Department, Nimes, France.
The study was presented at the 2024 ECTRIMS annual meeting.
Vitamin D Supplementation Versus Placebo
Research shows vitamin D deficiency is a risk factor for MS. However, results of previous research investigating vitamin D supplementation in MS, with different regimens and durations, have been contradictory.
The current double-blind study included 303 adults newly diagnosed with CIS (within 90 days) and a serum 25-hydroxy vitamin D concentration of less than 100 nmol/L at baseline. Participants had a median age of 34 years, and 70% were women.
About one third of participants had optic neuritis, two thirds had oligoclonal bands from cerebrospinal fluid analysis, and the median Expanded Disability Status Scale (EDSS) score was 1.0. Of the total, 89% fulfilled 2017 McDonald criteria for the diagnosis of relapsing-remitting MS (RRMS).
Participants were randomly assigned to receive high-dose (100,000 international units) oral cholecalciferol or placebo every 2 weeks for 24 months. Participants had a clinical visit at 3, 6, 12, 18, and 24 months, and brain and spinal cord MRI with and without gadolinium at 3, 12, and 24 months.
The primary outcome was occurrence of disease activity — relapse, new or enlarging T2 lesions, and presence of contrast-enhancing lesions.
Significant Difference
During follow-up, 60.3% in the vitamin group showed evidence of disease activity versus 74.1% in the placebo group (hazard ratio [HR], 0.66; 95% CI, 0.50-0.87; P = .004). In addition, the median time to evidence of disease activity was 432 days in the vitamin D group versus 224 days in the placebo group (P = .003).
“As you can see, the difference is really, really significant,” said Dr. Thouvenot, referring to a Kaplan-Meier curve. He said he was somewhat surprised by the “very rapid” effect of vitamin D.
He noted that the 34% reduction in relative risk for disease activity is “similar to that of some published platform therapies for CIS patients.”
An analysis of the 247 patients who met 2017 McDonald criteria for RRMS at baseline showed the same results.
Secondary analyses showed no significant reduction in relapses and no significant differences for annual change in EDSS, quality of life, fatigue, anxiety, or depression.
Additional analyses showed the HR was unchanged after adjusting for known prognostic factors including age, sex, number of lesions (< 9 vs ≥ 9), EDSS score at baseline, and delay between CIS and treatment onset.
Results showed vitamin D3 supplementation was safe and well tolerated. Dr. Thouvenot noted that 95% of participants completed the trial, and none of the 33 severe adverse events in 30 patients suggested hypercalcemia or were related to the study drug.
These encouraging new data support further studies of high-dose vitamin D supplementation as an add-on therapy in early MS, said Dr. Thouvenot. He noted that animal models suggest vitamin D added to interferon beta has a synergistic effect on the immune system.
‘Fabulous’ Research
During a question-and-answer session, delegates praised the study, with some describing it as “fantastic” or “fabulous.”
Addressing a query about why this study succeeded in showing the benefits of vitamin D while numerous previous studies did not, Dr. Thouvenot said it may be due to the longer duration or a design that was better powered to show differences.
Asked if researchers examined vitamin D blood levels during the study, Dr. Thouvenot said these measures are “ongoing.”
Responding to a question of whether high-dose vitamin D could be a lifelong treatment, he referred again to the “excellent” safety of the intervention. Not only is it well tolerated, but vitamin D benefits bones and the risk for hypercalcemia is low except perhaps for patients with tuberculosis or sarcoidosis, he said.
“When you exclude those patients, the safety is huge, so I don’t know why we should stop it once it’s started.”
This study was funded in part by the French Ministry of Health. Dr. Thouvenot reported no relevant disclosures.
A version of this article first appeared on Medscape.com.
FROM ECTRIMS 2024
Positive Stem Cell Transplant Data Is Increasing Its Use
COPENHAGEN —
With only one completed randomized trial available, HSCT remains experimental but the number of patients treated with this approach has now reached substantial numbers over 20 years of experience at multiple centers, according to two representative real-world studies presented at the 2024 ECTRIMS annual meeting.
The latest data are wholly consistent with a 2019 multinational randomized trial that found HSCT, which is a one-time intervention, to be relatively well tolerated and more effective than disease-modifying therapy (DMT) for median time to progression in patients refractory to DMT.
Relative to 24 months in the DMT group, median time to relapse was not reached among those randomized to HSCT because there were too few events. The hazard ratio (HR) reduction for progression was greater than 90% (HR, 0.07; P < 0.001). Other endpoints, such as EDSS, which improved in the group receiving HSCT but declined on DMT, also favored the single-treatment therapy.
Two Real-World Experiences With HSCT Reported
Of the two multicenter real world studies presented at ECTRIMS, one included 363 patients treated at one of 14 participating public hospitals in the United Kingdom since 2002. This analysis was uncontrolled. The other, with 97 patients treated at one of 20 participating centers in Italy since 1999, compared HSCT to alemtuzumab retrospectively.
In the UK data, presented by Paolo Muraro, MD, PhD, Senior Consultant, Division of Brain Sciences, Imperial College, London, England, 94.6% were in relapse-free survival (RFS) at 2 years and 88.6% at 5 years after undergoing HSCT. He called these numbers “impressive.”
In addition, MRI-free activity survival (MFS) was 88.2% and 78.8% at 2 and 5 years, respectively, Dr. Muraro said.
On the Expanded Disability Status Scale (EDSS), the cumulative incidence of improvement was 24.6% at 2 years and 28.6% at 5 years. There was no evidence of disease activity on the endpoints of symptoms, relapse, and MRI (NEDA-3) in 72% of patients at 2 years and 48.5% at 5 years.
Relative to historical response rates in a refractory population, Dr. Muraro considered these results favorable. Although there were four deaths, producing a treatment-related mortality of 1.1%, all occurred at an early stage of the HSCT program when there was limited experience in the management of cytopenias and other acute complications of HSCT.
“In this real-world cohort, stem cell transplant led to a durable remission of inflammatory activity and to clinical stability even though this included patients with a high EDSS at baseline [median 6.0] and a substantial proportion [39%) with progressive disease,” Dr. Muraro said.
In the Italian data, presented by Alessio Signori, MD, PhD, associate professor, Department of Health Sciences, University of Genoa, Italy, the 97 HSCT patients were matched with 314 treated with alemtuzumab over the same period and compared with propensity score overlap weighting. Baseline features were comparable.
HSCT Outperforms Alemtuzumab on All Measures
After a median follow-up of 62 months in the HSCT group and 30 months in the alemtuzumab group, HSCT outperformed drug therapy on all efficacy measures. When translated into HR, HSCT relative to alemtuzumab was associated with a 50% reduction in the probability of disability progression (HR, 0.50; P = 0.025), a 66% reduction in probability of relapse (HR, 0.34; P < 0.001), and a 62% reduction in the probability of MRI activity (HR, 0.38; P < 0.001).
“At 5 years, 58.3% of patients in the HSCT group versus 22.3% of the patients in the alemtuzumab group maintained NEDA-3,” said Dr. Signori, who reported that this difference represented a greater than 50% reduction (HR, 0.48; P < 0.001).
In this study there were two treatment-related deaths. Both occurred within 30 days of HSCT and, again, were confined to the early experience with HSCT.
There are questions that remain unanswered, such as whether there are predictors of response to HSCT. Although sustained responses have been greater on HSCT than drug therapy on average, poor responses appeared to be more common among those with a progressive phenotype in the UK experience.
Although patients with progressive disease were excluded from the Italian study, a real-world experience published 2 years ago also indicated that patients with progressive forms of MS respond less well to HSCT. Conducted in the United States at a single center (Northwestern University, Chicago) with 414 patients of whom 93 had progressive disease, EDSS progressively declined over the 5 years of follow-up among those with secondary progressive MS even as it improved in those with relapsing-remitting multiple sclerosis.
HSCT Considered on Compassionate Basis
Overall, the HSCT experience as a rescue therapy for MS patients with an inadequate response to DMT has led a growing number of centers active in this area to offer this option on a compassionate basis, according to Dr. Muraro and Dr. Signori. Joachim Burman, MD, PhD, who was the moderator of the scientific session at ECTRIMS and the leader of a research program into HSCT for MS at Uppsala University, Uppsala, Sweden, agreed.
The increasing number of centers offering HSCT to MS patients does not preclude the need or the value of the ongoing phase 3 trials, according to Dr. Burman, but he suggested that there is a growing focus of how it should be used, not whether it will be used.
Ultimately, he speculated that HSCT, once accepted as a mainstream option for MS, will probably be confined to the 5%-10% of patients with very aggressive disease. This is not for lack of safety or efficacy, but he sees several barriers to using this approach first-line, outside of special situations.
“You need a team of several different specialists to offer HSCT,” he said, suggesting that this approach to MS is much more complicated than a visit to a neurologist’s office for a DMT prescription. However, he thinks other barriers, such as concern about safety, are dissipating.
HSCT “is still being characterized as a high-risk procedure, but I would object to that,” he said. “The deaths associated with HSCT largely occurred 20 years ago when the field was new.”
Dr. Muraro reported a financial relationship with Cellerys AG that is unrelated to this study. Dr. Signori reported financial relationships with Chiesi, Horizon, and Novartis. Dr. Burman reports no potential conflicts of interest.
COPENHAGEN —
With only one completed randomized trial available, HSCT remains experimental but the number of patients treated with this approach has now reached substantial numbers over 20 years of experience at multiple centers, according to two representative real-world studies presented at the 2024 ECTRIMS annual meeting.
The latest data are wholly consistent with a 2019 multinational randomized trial that found HSCT, which is a one-time intervention, to be relatively well tolerated and more effective than disease-modifying therapy (DMT) for median time to progression in patients refractory to DMT.
Relative to 24 months in the DMT group, median time to relapse was not reached among those randomized to HSCT because there were too few events. The hazard ratio (HR) reduction for progression was greater than 90% (HR, 0.07; P < 0.001). Other endpoints, such as EDSS, which improved in the group receiving HSCT but declined on DMT, also favored the single-treatment therapy.
Two Real-World Experiences With HSCT Reported
Of the two multicenter real world studies presented at ECTRIMS, one included 363 patients treated at one of 14 participating public hospitals in the United Kingdom since 2002. This analysis was uncontrolled. The other, with 97 patients treated at one of 20 participating centers in Italy since 1999, compared HSCT to alemtuzumab retrospectively.
In the UK data, presented by Paolo Muraro, MD, PhD, Senior Consultant, Division of Brain Sciences, Imperial College, London, England, 94.6% were in relapse-free survival (RFS) at 2 years and 88.6% at 5 years after undergoing HSCT. He called these numbers “impressive.”
In addition, MRI-free activity survival (MFS) was 88.2% and 78.8% at 2 and 5 years, respectively, Dr. Muraro said.
On the Expanded Disability Status Scale (EDSS), the cumulative incidence of improvement was 24.6% at 2 years and 28.6% at 5 years. There was no evidence of disease activity on the endpoints of symptoms, relapse, and MRI (NEDA-3) in 72% of patients at 2 years and 48.5% at 5 years.
Relative to historical response rates in a refractory population, Dr. Muraro considered these results favorable. Although there were four deaths, producing a treatment-related mortality of 1.1%, all occurred at an early stage of the HSCT program when there was limited experience in the management of cytopenias and other acute complications of HSCT.
“In this real-world cohort, stem cell transplant led to a durable remission of inflammatory activity and to clinical stability even though this included patients with a high EDSS at baseline [median 6.0] and a substantial proportion [39%) with progressive disease,” Dr. Muraro said.
In the Italian data, presented by Alessio Signori, MD, PhD, associate professor, Department of Health Sciences, University of Genoa, Italy, the 97 HSCT patients were matched with 314 treated with alemtuzumab over the same period and compared with propensity score overlap weighting. Baseline features were comparable.
HSCT Outperforms Alemtuzumab on All Measures
After a median follow-up of 62 months in the HSCT group and 30 months in the alemtuzumab group, HSCT outperformed drug therapy on all efficacy measures. When translated into HR, HSCT relative to alemtuzumab was associated with a 50% reduction in the probability of disability progression (HR, 0.50; P = 0.025), a 66% reduction in probability of relapse (HR, 0.34; P < 0.001), and a 62% reduction in the probability of MRI activity (HR, 0.38; P < 0.001).
“At 5 years, 58.3% of patients in the HSCT group versus 22.3% of the patients in the alemtuzumab group maintained NEDA-3,” said Dr. Signori, who reported that this difference represented a greater than 50% reduction (HR, 0.48; P < 0.001).
In this study there were two treatment-related deaths. Both occurred within 30 days of HSCT and, again, were confined to the early experience with HSCT.
There are questions that remain unanswered, such as whether there are predictors of response to HSCT. Although sustained responses have been greater on HSCT than drug therapy on average, poor responses appeared to be more common among those with a progressive phenotype in the UK experience.
Although patients with progressive disease were excluded from the Italian study, a real-world experience published 2 years ago also indicated that patients with progressive forms of MS respond less well to HSCT. Conducted in the United States at a single center (Northwestern University, Chicago) with 414 patients of whom 93 had progressive disease, EDSS progressively declined over the 5 years of follow-up among those with secondary progressive MS even as it improved in those with relapsing-remitting multiple sclerosis.
HSCT Considered on Compassionate Basis
Overall, the HSCT experience as a rescue therapy for MS patients with an inadequate response to DMT has led a growing number of centers active in this area to offer this option on a compassionate basis, according to Dr. Muraro and Dr. Signori. Joachim Burman, MD, PhD, who was the moderator of the scientific session at ECTRIMS and the leader of a research program into HSCT for MS at Uppsala University, Uppsala, Sweden, agreed.
The increasing number of centers offering HSCT to MS patients does not preclude the need or the value of the ongoing phase 3 trials, according to Dr. Burman, but he suggested that there is a growing focus of how it should be used, not whether it will be used.
Ultimately, he speculated that HSCT, once accepted as a mainstream option for MS, will probably be confined to the 5%-10% of patients with very aggressive disease. This is not for lack of safety or efficacy, but he sees several barriers to using this approach first-line, outside of special situations.
“You need a team of several different specialists to offer HSCT,” he said, suggesting that this approach to MS is much more complicated than a visit to a neurologist’s office for a DMT prescription. However, he thinks other barriers, such as concern about safety, are dissipating.
HSCT “is still being characterized as a high-risk procedure, but I would object to that,” he said. “The deaths associated with HSCT largely occurred 20 years ago when the field was new.”
Dr. Muraro reported a financial relationship with Cellerys AG that is unrelated to this study. Dr. Signori reported financial relationships with Chiesi, Horizon, and Novartis. Dr. Burman reports no potential conflicts of interest.
COPENHAGEN —
With only one completed randomized trial available, HSCT remains experimental but the number of patients treated with this approach has now reached substantial numbers over 20 years of experience at multiple centers, according to two representative real-world studies presented at the 2024 ECTRIMS annual meeting.
The latest data are wholly consistent with a 2019 multinational randomized trial that found HSCT, which is a one-time intervention, to be relatively well tolerated and more effective than disease-modifying therapy (DMT) for median time to progression in patients refractory to DMT.
Relative to 24 months in the DMT group, median time to relapse was not reached among those randomized to HSCT because there were too few events. The hazard ratio (HR) reduction for progression was greater than 90% (HR, 0.07; P < 0.001). Other endpoints, such as EDSS, which improved in the group receiving HSCT but declined on DMT, also favored the single-treatment therapy.
Two Real-World Experiences With HSCT Reported
Of the two multicenter real world studies presented at ECTRIMS, one included 363 patients treated at one of 14 participating public hospitals in the United Kingdom since 2002. This analysis was uncontrolled. The other, with 97 patients treated at one of 20 participating centers in Italy since 1999, compared HSCT to alemtuzumab retrospectively.
In the UK data, presented by Paolo Muraro, MD, PhD, Senior Consultant, Division of Brain Sciences, Imperial College, London, England, 94.6% were in relapse-free survival (RFS) at 2 years and 88.6% at 5 years after undergoing HSCT. He called these numbers “impressive.”
In addition, MRI-free activity survival (MFS) was 88.2% and 78.8% at 2 and 5 years, respectively, Dr. Muraro said.
On the Expanded Disability Status Scale (EDSS), the cumulative incidence of improvement was 24.6% at 2 years and 28.6% at 5 years. There was no evidence of disease activity on the endpoints of symptoms, relapse, and MRI (NEDA-3) in 72% of patients at 2 years and 48.5% at 5 years.
Relative to historical response rates in a refractory population, Dr. Muraro considered these results favorable. Although there were four deaths, producing a treatment-related mortality of 1.1%, all occurred at an early stage of the HSCT program when there was limited experience in the management of cytopenias and other acute complications of HSCT.
“In this real-world cohort, stem cell transplant led to a durable remission of inflammatory activity and to clinical stability even though this included patients with a high EDSS at baseline [median 6.0] and a substantial proportion [39%) with progressive disease,” Dr. Muraro said.
In the Italian data, presented by Alessio Signori, MD, PhD, associate professor, Department of Health Sciences, University of Genoa, Italy, the 97 HSCT patients were matched with 314 treated with alemtuzumab over the same period and compared with propensity score overlap weighting. Baseline features were comparable.
HSCT Outperforms Alemtuzumab on All Measures
After a median follow-up of 62 months in the HSCT group and 30 months in the alemtuzumab group, HSCT outperformed drug therapy on all efficacy measures. When translated into HR, HSCT relative to alemtuzumab was associated with a 50% reduction in the probability of disability progression (HR, 0.50; P = 0.025), a 66% reduction in probability of relapse (HR, 0.34; P < 0.001), and a 62% reduction in the probability of MRI activity (HR, 0.38; P < 0.001).
“At 5 years, 58.3% of patients in the HSCT group versus 22.3% of the patients in the alemtuzumab group maintained NEDA-3,” said Dr. Signori, who reported that this difference represented a greater than 50% reduction (HR, 0.48; P < 0.001).
In this study there were two treatment-related deaths. Both occurred within 30 days of HSCT and, again, were confined to the early experience with HSCT.
There are questions that remain unanswered, such as whether there are predictors of response to HSCT. Although sustained responses have been greater on HSCT than drug therapy on average, poor responses appeared to be more common among those with a progressive phenotype in the UK experience.
Although patients with progressive disease were excluded from the Italian study, a real-world experience published 2 years ago also indicated that patients with progressive forms of MS respond less well to HSCT. Conducted in the United States at a single center (Northwestern University, Chicago) with 414 patients of whom 93 had progressive disease, EDSS progressively declined over the 5 years of follow-up among those with secondary progressive MS even as it improved in those with relapsing-remitting multiple sclerosis.
HSCT Considered on Compassionate Basis
Overall, the HSCT experience as a rescue therapy for MS patients with an inadequate response to DMT has led a growing number of centers active in this area to offer this option on a compassionate basis, according to Dr. Muraro and Dr. Signori. Joachim Burman, MD, PhD, who was the moderator of the scientific session at ECTRIMS and the leader of a research program into HSCT for MS at Uppsala University, Uppsala, Sweden, agreed.
The increasing number of centers offering HSCT to MS patients does not preclude the need or the value of the ongoing phase 3 trials, according to Dr. Burman, but he suggested that there is a growing focus of how it should be used, not whether it will be used.
Ultimately, he speculated that HSCT, once accepted as a mainstream option for MS, will probably be confined to the 5%-10% of patients with very aggressive disease. This is not for lack of safety or efficacy, but he sees several barriers to using this approach first-line, outside of special situations.
“You need a team of several different specialists to offer HSCT,” he said, suggesting that this approach to MS is much more complicated than a visit to a neurologist’s office for a DMT prescription. However, he thinks other barriers, such as concern about safety, are dissipating.
HSCT “is still being characterized as a high-risk procedure, but I would object to that,” he said. “The deaths associated with HSCT largely occurred 20 years ago when the field was new.”
Dr. Muraro reported a financial relationship with Cellerys AG that is unrelated to this study. Dr. Signori reported financial relationships with Chiesi, Horizon, and Novartis. Dr. Burman reports no potential conflicts of interest.
FROM ECTRIMS 2024