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Supplements Multiple Sclerosis: A Review of Diagnosis and Management

Multiple Sclerosis: The Safety-Efficacy Balance and Preventing Neurodegeneration

Introduction

The treatment landscape for multiple sclerosis (MS) has seen extensive growth over the last several decades. While the field still lacks universally accepted, algorithm-based treatment guidelines for the management of multiple sclerosis (MS),1 available guidelines advocate that patients should have open access to any currently approved disease-modifying therapies (DMTs).2,3 

Historically, initial treatment with DMTs begins with first-generation injectable products (ie, interferon beta products and glatiramer acetate), as the efficacy and safety of these products are well understood.4 Treatment with first-generation injectable products require frequent subcutaneous or intramuscular injections, are moderately effective, and are not associated with rare, life-threatening adverse reactions (such as infections and cancers).4,5 Although oral agents and recently approved injectable products are associated with improved efficacy, they have been associated with serious adverse reactions, some of which are life-threatening.4 (See Figure 1 and Figure 2.)

When patients are diagnosed with MS and have their first neurological symptoms, axonal loss has already occurred.6 Because brain atrophy, specifically gray matter atrophy, creates permanent damage and correlates with physical and cognitive disability, there is a need to treat the disease process as early as possible.

When evaluating currently approved DMTs, those that modulate CD8+ T cell proliferation (eg, dimethyl fumarate) appear to have neuroprotective benefits.7 Much of the current research in MS involves the identification of remyelination therapies that can reverse the neurodegenerative damage that occurs in MS.

Evidence-Based Treatment Guidelines

Despite the lack of universally accepted algorithm-based treatment guidelines for MS, the 2007 Consensus Statement from the National Clinical Advisory Board of the National Multiple Sclerosis Society made suggestions regarding the use of interferon beta products, glatiramer acetate, and mitoxantrone.2 According to the guidelines, a patient’s access to medication should not be limited by their age, frequency of relapses, or level of disability. Moreover, treatment should not be delayed or discontinued while insurers evaluate for continuing treatment coverage, as this would put patients at increased risk for recurrent disease activity. The guidelines also note that therapy should be continued indefinitely except if patients experience a clear lack of benefit, intolerable adverse effects, or if better therapy becomes available. Changing from one DMT to another should be medically justifiable, according to the guidelines.2

Additionally, the guidelines indicate that all FDA-approved agents should be included in formularies and covered by third-party payers to help physicians and patients determine the most appropriate agent on an individual basis; failure to do so is unethical and discriminatory.2 Importantly, none of these therapies have been approved for use for women who are pregnant or trying to become pregnant, or for nursing mothers.2 Figure 1 and Figure 2 offer information on the risks and benefits that should be taken into consideration when selecting therapy.

Although the algorithm portion of this consensus statement is outdated, the recommendations related to access to DMTs are still applicable. A more recent Consensus Paper from the MS Coalition, released in 2014, also addresses access to DMTs.3 Both guidelines advocate that patients should have open access to any currently approved DMTs. 

Evaluating Efficacy

Efficacy plays an important role in the choice of an initial DMT treatment.8 For patients with mild or moderate disease, efficacy may be among many considerations, but for patients with more aggressive disease, efficacy may be more important than other factors.8

Patients with more aggressive disease are generally characterized by1:
  • Disease onset >40 years
  • Male gender
  • Initial symptoms being motor or cerebellar; polysymptomatic
  • High attack frequency in early disease
  • Incomplete recovery after first event
  • High load of T2 lesions and T1 black holes
  • Rapid growth of lesions
  • Multiple locations of lesions


Because there are no currently available biomarkers that predict response to particular DMTs, efficacy must be discussed at the population level using clinical trial data.8 However, head-to-head data are scarce. Additionally, it is difficult to compare results among trials because of the differences in trial characteristics (eg, differences in study populations and outcome measures).8 For example, earlier trials (prior to the millennium), included patients with higher Expanded Disability Status (EDS) and who had more disease activity compared with the trials conducted in the postmillennium period. (For more information regarding EDS, see Figure 3.)

When evaluating efficacy, it is also important for clinicians to understand that the relationship among inflammatory activity, concurrent or subsequent neurodegeneration, and disease progression that leads to disability remains inconclusive.8 Because long-term trial data are limited for the majority of DMTs, it not possible to ascertain the long-term benefits (>2 years) of DMTs on these parameters.

Evaluating response to DMTs is most commonly accomplished using relapse rates, magnetic resonance imaging (MRI) scans, EDS scoring, and Multiple Sclerosis Functional Composite (MSFC) scoring.9 For more information on assessing a patient’s therapeutic response, see Table 1.9,11-13

Safety Considerations

The currently available DMTs exert their effects on the immune system either by immunomodulatory or immunosuppressant effects, with some producing both.1 Risk can be mitigated through careful patient selection and close monitoring. Since the interferon beta products and glatiramer acetate have been on the market the longest, the safety risks for those products are well documented.8 Likewise, after 10-plus years of postmarketing data, the safety profile of natalizumab is also well documented.8 While the safety concerns with the oral agents and newer injectable DMTs are generally known, it is possible that new safety concerns could arise in postmarketing surveillance, either because exposure has not yet reached the required threshold of total patient years or because long-term data are insufficient.8,10

The interferon beta products and glatiramer acetate are generally associated with the fewest adverse events, in terms of number and severity. Products such as natalizumab, daclizumab*, and alemtuzumab, which have Risk Evaluation and Mitigation Strategies (REMS), are associated with more adverse events, in terms of number and severity, and require increased monitoring.8,10 See Table 2 for more information on monitoring considerations and use in pregnancy and lactation.4,14-23

Preventing Neurodegeneration

White Matter Versus Gray Matter Pathology

Multiple sclerosis has traditionally been considered a disease of white matter.24-26 More recent data suggest that there is also gray matter involvement, as the development of some clinical features, such as cognitive impairment, cannot be fully explained by the severity of white matter pathology alone.25 Gray matter lesions are clearly defined areas of demyelination within the cerebral cortex, basal ganglia, and gray matter of the spinal cord and brainstem.25 A growing body of evidence suggests that gray matter involvement and the mechanism of neurodegeneration are at least partially independent from inflammation.6,25

MRI is the most important diagnostic and monitoring tool to assess the onset and progression of MS.9 Since the introduction of MRI, white matter lesions tend to be easily and accurately visualized.25 In contrast, gray matter lesions are more difficult to visualize through traditional MRI scans and have a different underlying pathology.26 Gray matter is less inflammatory (with limited infiltration of immune cells), small and potentially undetectable (with insufficient spatial resolution), and hard to distinguish from normal surrounding tissues due to volume effects of nearby cerebrospinal fluid (CSF).26

Nonconventional MRI techniques are required to assess pathogenic processes associated with disease activity and progression, including the presence of gray matter pathology.24,25 These techniques can identify the underlying pathology within lesions and brain tissue which appear to be normal (such as edema, inflammation, demyelination, axon loss, and neurodegeneration). While newer imaging sequences (including ultra–high-field MRI and magnetic resonance spectroscopy) have greatly improved detection of gray matter lesions,25 these technologies are not readily available/accessible. Thus, a “gold standard” imaging model has not yet been developed for gray matter demyelination.

Gray Matter Atrophy Leads to Neurodegeneration and Cognitive Impairment

Over the past decade, results of several studies have demonstrated that brain volume reduction (atrophy), which is a measure of neurodegeneration, occurs faster in people with MS.9,10 Average brain volume loss per year is 0.5% to 1.0% in patients with MS compared with 0.1% to 0.3% in healthy individuals.9 The pathogenesis of brain atrophy in MS is complex and not completely clear. Importantly, emerging evidence suggests gray matter atrophy may be a more sensitive marker of the neurodegenerative process in MS than whole brain atrophy.24 The atrophy rate of gray matter in patients with relapsing MS is 3 to 4 times that of healthy patients; in secondary-progressive MS, it is 14 times that of healthy people.9,24

 
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