AJMC Staff

Patients younger than 50 years of age with a shorter duration of multiple sclerosis might be considered candidates for an autologous hematopoietic stem cell transplant (AHSCT).

Earlier this week, the National Medical Advisory Committee of the National Multiple Sclerosis Society published recommendations in 

 about this issue based on current research.

However, the committee also said further research is needed and said some issues remain unresolved. The committee also said the procedure should only be performed at centers with substantial experience and expertise.

The committee concluded that AHSCT may be a useful treatment option for patients with relapsing MS who demonstrate substantial breakthrough disease activity despite treatment with high-efficacy disease-modifying therapy (DMT) or who have contraindications to high-efficacy DMTs. 

They also said that AHSCT might work optimally in people who have had the disease for less than 10 years.

The recommendations note that previous research studies have concluded that the likelihood of benefit from AHSCT is much smaller for patients with progressive MS without recent disease activity. In addition, patients who are older and have greater disability have a greater risk for serious complications or death associated with the procedure.

Unanswered questions include how long disease duration should be; how much disease activity an appropriate candidate should have; if clinical activity should be required; and whether a patient presenting with very active disease should turn to AHSCT as a first-line therapy, among others.

Only a few centers offer the adequate amount of expertise and quality assurance oversight to perform AHSCT. In addition to needing accreditation, centers performing AHSCT for MS should have transplant teams that include not only hematologist-oncologists with extensive experience in AHSCT, but also neurologists with expertise in MS diagnosis and treatment.

The authors also noted that it is appropriate to weigh the costs between AHSCT and drug therapy when considering treatment options. The estimated cost for AHSCT is approximately $150,000 for 1-time treatment. DMTs cost about $80,000 or more a year.

A version of this story originally published on NeurologyLive. For more, 

Miller AE. Chitnis T, Cohen BA, Costello K, Sicotte NL, Stacom R. Autologous hematopoietic stem cell transplant in multiple sclerosis. JAMA Neurol. Published online October 26, 2020. doi: 10.1001/jamaneurol.2020.4025

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The procedure might work best in patients who have had multiple sclerosis (MS) for less than 10 years, the report said. 

New Recommendations Open Door a Bit to Stem Cell Transplant for MS

A recent review and meta-analysis found that low-dose ketamine (LDK) can be used in place of opioids for patients in 

 seeking care in the emergency department (ED).

Ketamine, given by infusion, is an old drug that been used since the 1960s for chronic pain; 

 released guidelines for its use in both acute and chronic pain.

 looked at the proportion of patients who experienced nausea and hypoxia (the safety profile) and pain control as well as the need for rescue pain relief (effectiveness) in LDK compared with morphine.

The systematic review and meta-analysis of 8 randomized controlled trials, winnowed down from 524 studies found in Medline and EMBASE, found similar results as previous studies, the authors said.

Data were pooled using random-effects models and reported as mean differences and risk ratios (RR) at 95% confidence intervals (CIs) and researchers used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework to assess the certainty of the evidence.

Out of a total of 1191 patients, 598 were given LDK and 593 received morphine; the authors found no significant difference in reported mean pain scores between the two within the first 60 minutes after pain relief was give. At 60 to 120 minutes, there was a slight difference in pain scores in favor of morphine. 

The need for rescue medication was also similar between groups (RR = 1.26; 95% CI, 0.50-3.16), as was the proportion of patients who experienced nausea (RR = 0.97; 95% CI, 0.63-1.49) and hypoxia (RR = 0.38; 95% CI, 0.10-1.41).

The doses of LDK that were used in the included studies varied from 0.2 to 0.5mg/kg, and the authors noted that dosing differences  may have affected study results.

All outcomes were judged to have low certainty in the evidence (out of very low, low, moderate or high). 

The study had several limitations common to all 

systematic reviews and meta‐analyses in that the results were limited by the quality of the included trials.

Ketamine's possible adverse events include laryngospasm, hypertension, tachycardia, and emergence reactions. 

Balzer N, McLeod S, Walsh C, Grewal KG. Low‐dose ketamine for acute pain control in the emergency department: A systematic review and meta‐analysis. 

Published online October 24, 2020. Doi: 10.1111/acem.14159

The study compared patients given-low-dose ketamine with those given morphine for acute pain relief.

Review of Ketamine in ED for Acute Pain Finds Similar Efficacy to Other Pain Relief

 cited an article published in the October 2020 issue of 

Inpatient-Outpatient Shared Electronic Health Records: Telemedicine and Laboratory Follow-up After Hospital Discharge

,” found that a seamlessly shared inpatient-outpatient electronic health record was associated with greater rates of postdischarge follow-up delivered through telemedicine or laboratory monitoring and without an in-person office visit. The study was additionally cited by 

 referenced an article published on AJMC.com, the website of 

Racial Disparities Persist in Maternal Morbidity, Mortality and Infant Health

,” examined review findings presented at the American Diabetes Association’s 80th Scientific Sessions, which indicated that American women die in childbirth at a higher rate than in any other developed country, while non-Hispanic Black women are more than 3 times more likely to have a maternal death than white women in the United States.

’s sister site The Center for Biosimilars

As Patents Expire, Oncology Biosimilars Poised to Expand, Authors Say

.” The article noted that by 2023, patents on nearly 20 oncology biologics will expire, which could lead to more biosimilars in cancer care and therefore reduced costs.

Coverage of our peer-reviewed research and news reporting in the health care and mainstream press.

AJMC® in the Press, October 30, 2020

Less than a week out from the November 3 general election, the United States has reported a record of nearly 90,000 new coronavirus disease 2019 (COVID-19) cases in one day, as spikes emerge in nearly every swing state, 

. Currently, 228,000 deaths have been linked to the disease while cases are expected to reach 9 million today, only 15 days after the tally hit 8 million. Meanwhile, state health officials warn they do not have enough money to adequately distribute a vaccine as the CDC tells them to be prepared by 

. The agency is asking states to provide information, such as a list of each jurisdiction’s top 5 sites capable of receiving and administering a vaccine, by Tuesday.

, found that among 104 workers tested at a grocery store in Massachusetts in May, 21 tested positive for COVID-19. However, among those with the virus, 76% were not showing any symptoms at the time of the test. Overall, workers who interacted with customers were 5 times more likely to test positive compared with those in other roles. At the time, the community reported a roughly 1% prevalence, highlighting how frontline workers are more vulnerable to infection. The study also evaluated employees’ mental states and showed those able to practice social distancing at work consistently exhibited significantly lower risks of anxiety or depression.

CRISPR Gene Editing Experiment Underscores Risks

A recent lab experiment that aimed to correct defective DNA in human embryos exhibited what can go wrong with this type of gene editing, underscoring concerns outlined by leading scientists on the safety of the procedure, The Associated Press 

. In more than half of the cases in the experiment, the procedure caused unintended changes like loss of an entire chromosome or big portions of it. Researchers used the CRISPR-cas9, the same tool Chinese scientists used on embryos in 2018 to create the world’s first gene-edited children. The tool is already used to raise superior crops and livestock and holds promise for future disease treatment. However, the use of the tool on embryos can make changes that may pass to future generations.

The United States sees a daily record in new coronavirus disease 2019 (COVID-19) cases; grocery workers are at a greater risk of COVID-19 infection; the risks of gene editing. 

Author | AJMC Staff

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New Recommendations Open Door a Bit to Stem Cell Transplant for MS

Review of Ketamine in ED for Acute Pain Finds Similar Efficacy to Other Pain Relief

AJMC® in the Press, October 30, 2020

What We’re Reading: COVID-19 Surges in Swing States; Grocery Workers’ High Risk of Infection; Risks of CRISPR Gene Editing