Friday, 31 October 2014

ClinicSpeak: update on Tecfidera PML case

#Tecfidera update: very low lymphocyte counts are the preventable PML risk factor. #ClinicSpeak #MSBlog #MSResearch

"Biogen-Idec have give us the green light to go public on the fact that the patient who developed PML, and died, whilst taking dimethyl fumarate (Tecfidera) had had a lymphocyte count of less than 500/mm3, or 0.5 X 10**9/L for over three and a half years."


"This information has led us to formulate the following interim guidelines to manage DMF-related lymphopaenia in our centre. These are not evidence-based, but are based on well founded immunological principles and anecdotal clinical observations to date."

"I would like to thank Biogen-Idec for being so responsive in providing the information in such a timely manner; we have also used the information their medical information department has provided us in the past to draft our interim guidelines (below)."

"I have also asked Biogen-Idec to look at their data in more detail to see if DMF-related lymphopaenia is reversible, and if it is reversible do the lymphocyte counts return to the pre-treatment baseline levels; this information will clearly impact on future updates of our guidelines."

Guidelines

1. Before starting DMF an up-to-date (within the last 4 weeks) full blood count (FBC) is required in addition to lymphocyte subsets*.

2. The monitoring of FBC with lymphocyte counts and subsets should be done at 3 months and 6 months, and then at 6 monthly intervals in patients with lymphocyte counts above 1.2 x 10**9/L. In patients with total lymphocyte counts less than 1.2 x 10**9/L monitoring should be done at 3 monthly intervals.

3. If the lymphocyte counts return to above 1.2 x 10**9/L, then 6 monthly monitoring should be reinstated.

4. If the total lymphocyte count falls below 0.8 x 10**9/L, and is confirmed on a second FBC and the patient wants to stay on DMF it may be worth checking the JCV virus status. As DMF-related lymphopaenia is a form of immunosuppression** the JCV index, as measured using the STRATIFY JCV assay, cannot be used to assess PML risk. Please note a lymphocyte count cut-off of 0.8 x 10**9/L (WHO grade 2) may considered by some as being too conservative; but until data emerges to show that DMF-related lymphopaenia is reversible we feel this conservative approach is justified.

5. If lymphocytes remain persistently below 0.8 x 10**9/L, consider the risks and benefits of continuing DMF.

6. If lymphocytes go below 0.5 x 10**9/L we recommend stopping DMF.

7. At present we are not aware of any data to indicate that reducing the dose of DMF will result in the lymphocyte counts recovering. In addition, a lower dose than 240mg BD of DMF is unlikely to be effective.

8. All patients treated with DMF should have annual Gd-enhanced MRI studies according to our Barts MS MRI protocol, and additional MRI studies if clinically indicated.

*At present we are not aware of the effect of DMF on the distribution of peripheral blood lymphocyte subsets; performing this test and collecting this data may affect clinical decision making and will provide much need information on the immunological effects of DMF in patients with MS.

**We define significant immunosuppression on DMF as persistent lymphopaenia for greater than 6 months with a total lymphocyte count of less than 1.2 x 109/L (WHO Grade 1). In patients with a past history of significant immunosuppression the JCV serology index, as measured using the STRATIFY JCV assay, cannot be used to complement PML risk profiling.


CoI: multiple

Migration shows early encounter with risk factor

ProfG made a post about the output of school kids and found that they seem to have a reduced output compared to non-Msers.

Yes this is depressing, but the other part of the MS jigsaw is  if you look at the at who have were born in a low-risk area and moved to a high risk area like the UK. The answer appears to be move before 15 and you take the risk of birth place. Understanding MS means explaining the observations of MS.
This says we encounter the risk factor many years before MS is diagnosed

Thursday, 30 October 2014

ClinicSpeak: when does MS actually begin?

How long is the asymptomatic period of MS? #ClinicSpeak #MSBlog #MSResearch

"The data below was presented at last year's AAN meeting in San Diego and I have been presenting it in my talks ever since. It supports my MS dementia rebranding exercise. In Argentina all people do standardised examinations in the last 3 years of school. If someone develops a clinically isolated syndrome (CIS) after leaving school you can go back an look at their school performance and compare them to matched control subjects. What this study shows that cognitive performance in the last 3 years of school is poorer in subjects presenting with CIS after school compared to appropriately matched control subjects. Interestingly, cognitive performance was worse in subjects the closer their CIS presentation occurred after school. It appears as if the effect on cognition was noted up to 10 years after leaving school. What does this mean? It is telling us that MS has a long asymptomatic period that is obviously culling cognitive ability years before the first clinical attack. This is similar to the prodrome, called minimal cognitive impairment (MCI), that is seen in people who go onto develop Alzheimer's disease."


"Should you be surprised by these findings? Not really, these observations are congruent with several other observations. Firstly, most people presenting with CIS have several older lesions on their MRI indicating that the disease has been presented for sometime prior to the new lesion causing their CIS. People with both clinically-isolated and radiologically-isolated syndromes (RIS) often have pre-existing brain atrophy and cognitive impairment indicative of the disease being present for a period of time. Children presenting with CIS, or MS, have smaller brains than children presenting with acute disseminated encephalomyelitis (ADEM) indicating that MS has an asymptomatic period affecting brain development and ADEM, a monophasic disease, does not."



"How long is the asymptomatic period of MS? These data would suggest it being years and possibly loner than 10 years. This sets a challenge for us to try and diagnose MS in the presymptomatic phase so that we can try intervene earlier in the course of the disease. This was one of the drivers of our so called endophenotype project. The question is would someone start treatment before they have a clinical attack? This is happening already; I am aware of several neurologist across the globe who has patients with RIS (asymptomatic MS) on DMTs. Please note treating RIS would not be allowed in the UK and at presenting RIS is not part of the diagnostic criteria of MS. I suspect this will change in the future; MS is a biological disease before it is a clinical disease!"

Epub: Sinay et al. School performance as a marker of cognitive decline prior to diagnosis of multiple sclerosis. Mult Scler. 2014. pii: 1352458514554054.

BACKGROUND: For many years, cognitive impairment has been established as a well-known symptom of MS. Moreover, we know that it was present even at the beginning of the disease.

OBJECTIVE: In this case-control study, we decided to evaluate whether there is an impairment of cognitive functions even before onset in those people who will eventually suffer from multiple sclerosis.


METHODS: We evaluated the overall school performance, and particularly school performance in math and language in a group of people who would later develop the disease and we compared our findings with a control group.


RESULTS: We found that school performance was poorer in subjects who were to become patients. And we found that the later the start of the first symptom, the better the qualifications.


CONCLUSION: Testing a premorbid cognitive deficit by a validated indirect evaluation method allowed us to verify that there was evidence of neurological compromise even before a clinical diagnosis or the completion of the first magnetic resonance imaging in patients who would then suffer from multiple sclerosis.

MouseDoctor-The Joker

Someone made a Complaint that I was a "Joker". I wonder why you would think that?  :-)
P.S. You have freedoms to make comments but not to Insult. 

You may or may not like our styles or contents of the posts. If you no likey....no readie :-)


So some don't like "The Joker" They prefer Groucho Marx


IV IG making false positives for JC Virus

Kister I, Kuesters G, Chamot E, Omari M, Dontas K, Yarussi M, Subramanyam M, Herbert J. IV immunoglobulin confounds JC virus antibody serostatus determination. Neurol Neuroimmunol Neuroinflamm. 2014 Sep 18;1(3):e29. doi: 10.1212/NXI.0000000000000029. eCollection 2014 Oct.

OBJECTIVE:To determine the impact of therapeutic infusion of IV immunoglobulin (IVIg) on John Cunningham virus antibody (JCV Ab) serostatus and level in serum.
METHODS:  We carried out a retrospective analysis of serum levels of JCV Ab among STRATIFY-2 trial enrollees from 2 multiple sclerosis centers who were exposed to IVIg during the trial. For the subset of eligible patients, we estimated mean linear trends while on IVIg and after stopping IVIg with a linear mixed-effects model.
RESULTS: The JCV Ab seropositivity rate in the group of patients that was recently exposed to IVIg was 100%, which is significantly higher than in the IVIg-naive population (58%, p < 0.001). The seropositivity rate in the patient group with remote IVIg exposure was similar to that in the IVIg-naive population (67%, p = 0.68, Fisher exact test). The slope of the linear trend line after stopping IVIg decreased significantly by -0.310 units per 100 days (95% confidence interval, -0.611 to -0.008; p = 0.04).
CONCLUSIONS: Recent IVIg exposure is invariably associated with JCV Ab seropositivity. After stopping IVIg, JCV Ab levels tend to decrease with time, and seroreversion to innately Ab-negative status can occur.


Intravenous immunoglobulin is a the antibodies from a large pool  of over a thousand people and if you get this for your MS, then it gives you the potential for a false positive anti-JC virus test,

Wednesday, 29 October 2014

Battle Plans Ready...

Let the crusades begin

ClinicSpeak: macrophages infiltrates after alemtuzumab in a patient with NMO

What does the pathology of a case of NMO teach us about alemtuzumab? #MSResearch #MSBlog #ClinicSpeak

"The case report below is of a patient with anti-aquaporin-4 NMO who was treated with alemtuzumab. Unfortunately the patient died and at post-mortem the pathology showed extensive innate immune activation, i.e. extensive macrophage infiltration, with very little lymphocytes. It is clear this patient did not respond to alemtuzumab in that she had a recurrent attack and died from a large lesion and extensive lesion involving the brain stem and brain. The brain MRI lesions of this patient are very atypical for NMO and I wonder if she may have succumbed to another condition, for example progressive multifocal leukoencephalopathy or PML; the pathological description does not mention tests to exclude PML. Outside the context of MS alemtuzumab has been linked to PML, typically in patients with leukaemias and lymphomas. This poor woman had a very stormy course with multiple urinary tract infections, septicaemia, herpes zoster, a deep venous thrombosis in the leg, haematomas following plasma exchange, a broken femur after falling out of her wheelchair and an episode of Clostridium difficile colitis. She finally required a tube inserted for feeding directly into her stomach; i.e. a so called gastrostomy tube, before being discharged home."


"The interesting question is did alemtuzumab work in this patient and dos it work in NMO?  We have previously reported on the association between thyroid autoimmunity and the MS mimics, NMO (neuromyelitis optica) and TM (transverse myelitis), compared to MS in the past and I have speculated that alemtuzumab may not suitable for treating autoantibody mediated conditions such as NMO. This may relate to how alemtuzumab works and its complications; i.e. it may trigger and stimulate autoantibody production."

"Alemtuzumab's putative mode of action is via depleting your immune system and allowing it to recover spontaneously. Alemtuzumab kills or bursts open white blood cells, or leukocytes, by binding to a specific protein CD52 on the surface of the cell. When alemtuzumab binds to the cells it attracts a large number of other proteins, called complement, to the surface of the cells and these proteins pierce a hole in the cell causing it to burst. Complement is the family of proteins the immune system uses to kill damaged or cancerous cells and invading organisms. When the white cells burst they release their contents into the bloodstream; some of these substances are proteins that mediate the effects of inflammation on the body, which is why alemtuzumab causes an infusion reaction with a raised temperature, chills, rigors and a skin rash in most treated patients. To dampen down the infusion reactions we pretreat patients who are about to receive alemtuzumab with steroids, paracetamol and anti-histamines."

"Alemtuzumab is given as short courses on a yearly basis; daily for 5 days in the first year and then daily for 3 days in the second and subsequent years. Subsequent courses are only given if your MS has been shown to reactivate, i.e. you have relapses or develop new or enhancing lesions on MRI. The majority of MSers (two-thirds) only require 2 courses to go into long-term remission. A minority of MSers will require 3, 4 or very rarely 5 courses of alemtuzumab. Please note that reactivation of your MS after alemtuzumab does not mean that you have failed to respond to alemtuzumab it simply means you need another course, this is different to maintenance therapies (give continuously) were disease reactivation is an indication of non or suboptimal response."

"After each course the white cells recover by dividing or proliferating. When the immune system recovers there have been questions about whether or not it is competent to fight infections, cancers and whether or not it can remember the vaccines you have had in the past. A small study has shown that when the immune system recovers post-alemtuzumab it is competent and does remember the vaccinations you have had in the past. Another observation that tells us the immune system post-alemtuzumab is competent, or nearly competent, is the lack of so called opportunistic infections in alemtuzumab-treated MSers."

"There is one major caveat; when the white blood cell counts post-alemtuzumab are very low, or have not yet fully recovered MSers are at risk of herpes virus reactivation. Unfortunately, the lady below had herpes zoster. Once infected with herpes viruses they persist in the body in a dormant state and can reactivate when the immune system is stressed or compromised. To prevent this from occurring we prescribe prophylactic anti-viral drugs for about 6 weeks to prevent herpes virus reactivation. Despite doing this there is an approximately 1 in 50 chance of developing shingles after alemtuzumab treatment. In the clinical trials the majority of shingles cases were mild or moderate. It is also reassuring to know that shingles can be treated with anti-viral drugs."

"Whether or not MSers treated with alemtuzumab are at increased risk of developing secondary cancers is at present unknown. There have been too few MSers treated with alemtuzumab, and the ones who have been treated have been followed for too short a time, to answer this question. Therefore the increased cancer risk is a theoretical risk at present. In my opinion the cancer risk is low as we have not seen many of the so called indicator cancers, i.e. those cancers associated with drugs that target the immune system, in any of the MSers treated with alemtuzumab in the phase 3 trials. But on balance it is too early to make any judgement on this."

"The one risk from being treated with alemtuzumab is the development of secondary antibody-mediated autoimmune diseases that occur months to years after the last course of alemtuzumab. Autoimmune thyroid disease is the commonest disease and occurs in ~30% of treated MSers. The second most common is immune mediated thrombocytopenia, or ITP, that occurs in 2-3% of treated subjects. In ITP the immune system destroys the platelets or cells that help stop bleeding. A much more rare disease is so called Goodpasture's disease when the immune system makes antibodies that can damage the kidney. This last two diseases can be serious, but if detected early and treated most people make a good recovery. These autoimmune complications of alemtuzumab are why MSers who have been treated with the drug need to be monitored with monthly blood and urine tests for at least 4 years after the last course of treatment. Therefore if you are eligible for alemtuzumab and you want to be treated with this drug you are going to have to be adherent to the monitoring programme. If not and MSers die, or have near-death experiences, from these treatable complications the regulatory authorities may restrict alemtuzumab's use in the future. This would be unfair on those MSers who may wish to be treated with the drug in the future."

"The real advantage of alemtuzumab is the fact that it is an induction therapy; i.e. you get treated with the drug and you don't have to have it continuously. This has advantages for MSers who can't tolerate daily injection or oral therapies. Another advantage is the long-term remission that the majority of MSers go into after a two courses. Woman wanting to fall pregnant and start a family will find this attribute of the drug very appealing. What has been played down is that a large number of MSers who have disabilities find that they improve spontaneously after alemtuzumab. I don't think this is because alemtuzumab is a neurorestorative drug, but it simply reflects that when you suppress and stop inflammation in the brain and spinal cord you allow spontaneous recovery to occur. This is why I don't believe we need drugs to promote remyelination in MS; remyelination will occur spontaneously if we suppress inflammation with sufficiently effective therapies early in the disease course; a similar observation occurs with natalizumab or Tysabri. An important point regarding the spontaneous improvement post-alemtuzumab is the observation that it is more likely to occur early in the course of the disease, before the demyelinated axons die and there is sufficient reserve capacity to allow recovery. You can't remyelinate an axon that is not there; and this is why alemtuzumab has not be as effective in MSers in with secondary progressive MS."

Gelfand et al. Massive CNS monocytic infiltration at autopsy in an alemtuzumab-treated patient with NMO.Neurol Neuroimmunol Neuroinflamm. 2014 Oct 9;1(3):e34.

OBJECTIVES: To describe the clinical course and neuropathology at autopsy of a patient with neuromyelitis optica (NMO) treated with alemtuzumab.

RESULTS: A 61-year-old woman with aquaporin-4 immunoglobulin G antibody seropositive NMO had 10 clinical relapses in 4 years despite treatment with multiple immunosuppressive therapies. Alemtuzumab was administered and was redosed 15 months later. For the first 19 months after the initial alemtuzumab infusion, the patient did not experience discrete clinical relapses or have evidence of abnormally enhancing lesions on brain or spinal cord MRI. However, she experienced insidiously progressive nausea, vomiting, and vision loss, and her brain MRI revealed marked extension of cortical, subcortical, and brainstem T2/fluid-attenuated inversion recovery (FLAIR) hyperintensities. She died 20 months after the initial alemtuzumab infusion. Acute, subacute, and chronic demyelinating lesions were found at autopsy. Many of the lesions showed marked macrophage infiltration with a paucity of lymphocytes.

CONCLUSIONS: Following alemtuzumab treatment, there appeared to be ongoing innate immune activation associated with tissue destruction that correlated with nonenhancing T2/FLAIR hyperintensities on MRI. We interpret the cessation of clinical relapses, absence of contrast-enhancing lesions, and scarcity of lymphocytes at autopsy to be indicative of suppression of adaptive immunity by alemtuzumab. This case illustrates that progressive worsening in NMO can occur as a consequence of tissue injury associated with monocytic infiltration. This observation may be relevant to multiple sclerosis (MS) as well as NMO and might explain why in previous studies of secondary progressive MS alemtuzumab did not seem to inhibit disability progression despite a dramatic decline in contrast-enhancing lesions.

CoI: multiple

Natural History Studies

This is a retrospective study using the MS Registry in Kuwait. They took a cohort of patients and looked at certain variables to see if they were predictive of MS progression.

The study is not revolutionary in its findings - it shows that a late age of onset, male gender and relapse frequency are all poor prognostic markers and increase the risk of progression to secondary-progressive MS. Furthermore, spinal cord relapses are worse than optic neuritis. 

I suppose the main take-home message from this study is that when deciding on treatments it is worthwhile trying to think about where your risk lies on the MS spectrum - one may be more inclined to go for a stronger drug earlier on if  you know that you have a number of poor prognostic indicators and vice versa. 

Prof G posted last year on the epidemic of MS in Kuwait and stated he felt this was likely due to women spending less time outdoors - this is a similar picture to Iran.


Clinical predictors of disease progression in multiple sclerosis patients with relapsing onset in a nation-wide cohort

Alroughani RA, Akhtar S, Ahmed SF, Al-Hashel JY.
Int J Neurosci. 2014 20:1-17. [Epub ahead of print]

Background: Predicting disease progression over time is challenging despite the available literature data.


Aim: To assess whether baseline clinical variables of MS patients would predict the conversion to progressive phase of the disease. Materials & methods: Utilizing the national MS registry, patients who had relapsing onsets and had confirmed EDSS score at baseline and follow-up visits were included. Primary progressive MS and CIS patients were excluded. Clinical variables (gender, age at onset, disease duration, number of relapses, EDSS score) were collected. The end point was conversion to secondary progressive MS. Chi Square and multivariable logistic regression were used to determine the influence of clinical variables on disease progression. Results: Data of 803 MS patients with relapsing onset were analyzed. Eighty five (10.6%) patients reached the end point. The risk of disease progression was significantly higher is men (P = 0.015), in patients who developed MS ≥ 40 years of age (P = 0.041) and who had ≥ 3 relapses during their disease course (P < 0.001). Spinal cord presentation at onset was predictive of progression (aOR = 2.01; P = 0.06) while optic neuritis at onset was associated with lower risk of progression (aOR = 0.30; P = 0.03). EDSS score at first visit did not influence disease progression when tested at 2 different cutoffs (EDSS < 4 vs. ≥ 4 and EDSS < 6 vs. ≥ 6) using multivariable logistic regression analysis (P = 0.960 and P = 0.866) respectively.


Conclusion: Men and patients who presented at age 40 yeas or beyond had increased risk of MS progression. Spinal cord symptoms at onset and 3 or more relapses were predictive of progression

Extended interval dosing of natalizumab

Bomprezzi R, Pawate S. Extended interval dosing of natalizumab: a two-center, 7-year experience. Ther Adv Neurol Disord. 2014;7(5):227-31

BACKGROUND:The enthusiasm for natalizumab, a highly efficacious agent in the treatment of multiple sclerosis (MS), has been tempered by the risks of progressive multifocal leukoencephalopathy associated with its use, and strategies to minimize those risks are of great interest. Extended interval dosing (EID) has been proposed as a way to maintain the efficacy of natalizumab while reducing exposure to it. We reviewed a cohort of patients who received natalizumab at 6-8-week intervals instead of the typical infusions every 4 weeks with the goal to assess if patients on EID had an increase in clinical relapses.
METHODS:This is a retrospective review of all patients with MS treated with natalizumab at two MS centers where patients were offered the opportunity to switch to an EID every 6 or 8 weeks.
RESULTS:A total of 361 patients received natalizumab for 22 ± 13 months (minimum duration 6 months). Of these, 96 patients received EID natalizumab at some point for 20 ± 11 months (minimum duration 6 months). Over the study period, there was no significant difference between the relapse rate in the monthly dosing (13%) and the EID (13%) groups of patients.
CONCLUSION:Natalizumab is effective in controlling MS as very few clinical relapses were observed in our dataset. We found that EID did not compromise the treatment effect as measured by relapse rate and no significant breakthrough disease activity was observed. EID is an optional regimen for maintenance natalizumab therapy, but prospective studies are warranted to determine its efficacy.



Tysabri is typically administered every month, but this study looked and found that there was no more disease breakthrough if the interval between injections was extended to 6-8 weeks.  We know that from switching tysabri that disease returns once you stop and it takes a few weeks for the tysabri to get out of your system. 

If we wanted to be scientific about this, as we know that tysabri works because it blocks CD49d/VLA-4 on white blood cells. If we added a labelled antibody against CD49d and it could not bind because tysabri is working, with time new CD49d would be produced and then the labelled antibody would bind. Once a certain level of free CD49d is present, disease can return. So you could check this with a blood sample. It would take about 30-40min for me to do it and you could know if you are an individual you removes tysabri from the system quickly where EID may not be appropriate or someone who does this slowly and where EID may be more appropriate. The cost o the extra tests could be offset by reduced drug cost.However, its in the Interest of Biogen to sell you as much drug as possible. Look at Teva...they spent years telling you to inject daily yet once their patent for Copaxone runs out they come up with a formulation that only requires 3 times a week injections. 

Tuesday, 28 October 2014

OffLabel: cyclophosphamide

Cyclophosphamide is my fifth off label DMT for treating MS in resource poor environments. #MSBlog #MSResearch #OffLabel

"This post is the fifth in a series of posts to try and help neurologists who treat MS in healthcare environments where they cannot access high-cost innovator DMTs. If you want to know the history of this post please read my post on my visit to South Africa. The other four off-label DMTs that I have covered to date are methotrexate, azathioprinemitoxantrone and cladribine."

"I wasn't going to include cyclophosphamide in this list as I personally haven't personally used it to treat MS for close to 20 years. However, I discovered at a recent meeting that quite a number of colleagues are still using the drug in tumefactive and Marburg-variant MS as an induction therapy and they also use it in some patients with highly-active/rapidly-evolving MS in whom they can't use mitoxantrone."


"Tumefactive MS is uncommon and presents with a space-occupying lesion in the brain that looks like a tumour on MRI or CT scan. When these tumour-like lesions are biopsied they turn out be MS. I have several patients that I follow in clinic who presented with tumefactive MS and have now gone onto have a typical relapsing-remitting course. In addition, we occasionally see patients with typical MS who then present with a tumefactive lesion. We usually biopsy these lesions in established MS as MSers are a likely as the general population to develop brain tumours. Interestingly, I have had one tumefactive presentation as part of natalizumab-rebound. In the latter case we did not biopsy the lesion and it slowly regressed. Marburg's MS variant, or acute fulminant MS, is considered to a be MS variant by many, but some feel it is a different diseases. Marburg patients have a fulminant or malignant course typically over a period of weeks to months."

"What about using cyclophosphamide to treat progressive MS? The trial data is not convincing and the observations with the drug are not too dissimilar to what happens with mitoxantrone and other powerful anti-inflammatory drugs; you switch off relapses and MRI activity, but patients tend to continue to progress. It appears as if the progression post cyclophosphamide may be slower that before cyclophosphamide, similar to what occurs with mitoxantrone. The risk:benefit ratio of cyclophosphamide and mitoxantrone in progressive MS is not good, particularly if patients have bladder dysfunction and need an indwelling catheter. The latter not only puts them at risk of getting infections, but the bacteria in the bladder interact with the breakdown products of cyclophosphamide to cause bladder cancer. This is such a problem that the need to catheterise yourself is a relative contra-indication to using cyclophosphamide. We can de-risk this problem slightly by administering mesna a drug that is also excreted in the urine and that protects the bladder from the cyclophosphamide metabolites."

"The above commentary is referring to pulsed intravenous treatment; what about oral cyclophosphamide? The latter can be used for 3-4 months only; the chronic exposure of the bladder to cyclophosphamide metabolites cause a rare, but potentially fatal, complication called haemorrhagic cyctitis. I personally try to avoid using oral cyclophosphamide."

"What dose of cyclophosphamide? There as many regimens of cyclophosphamide out there as there MS patients needing treatment with it. I tend to round the dose depending on body size (~15mg/kg) to either 750mg, 1000mg or 1250mg intravenously 4-weekly, for 4-6, doses in combination with 1g of methylprednisolone. Patients need to be counselled about side effects and the potential impact on fertility. Most MSologists have a lot of experience with using pulsed cyclophosphamide as it is our treatment of choice for CNS vasculitis and CNS SLE; therefore they don't need detailed instructions on how to use it."

"I would like to take this opportunity to thank many of my colleagues who are supporting my OffLabel initiative; knowing that this may be of value to some MSers in the world makes a big difference to me."


La Mantia et al. Cyclophosphamide for multiple sclerosis. Cochrane Database Syst Rev. 2007 Jan 24;(1):CD002819.

BACKGROUND: MS is a presumed cell-mediated autoimmune disease of the central nervous system. Cyclophosphamide (CFX) is a cytotoxic and immunosuppressive agent, used in systemic autoimmune diseases. Controversial results have been reported on its efficacy in MS. We conducted a systematic review of all relevant trials, evaluating the efficacy of CFX in patients with progressive MS.


OBJECTIVES: The main objective was to determine whether CFX slows the progression of MS.

SEARCH STRATEGY: We searched the Cochrane MS Group Trials Register (searched June 2006), Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 3 2006), MEDLINE (January 1966 to June 2006), EMBASE (January 1988 to June 2006) and reference lists of articles. We also contacted researchers in the field.

SELECTION CRITERIA: Randomised controlled trials (RCTs) evaluating the clinical effect of CFX treatment in patients affected by clinically definite progressive MS. CFX had to be administered alone or in combination with adrenocorticotropic hormone (ACTH) or steroids. The comparison group had to be placebo or no treatment or the same co-intervention (ACTH or steroids)

DATA COLLECTION AND ANALYSIS: Two reviewers independently decided the eligibility of the study, assessed the trial quality and extracted data. We also contacted study authors for original data.

MAIN RESULTS: Of the 461 identified references, we initially selected 70: only four RCTs were included for the final analysis. Intensive immunosuppression with CFX (alone or associated with ACTH or prednisone) in patients with progressive MS compared to placebo or no treatment (152 participants) did not prevent the long-term (12, 18, 24 months) clinical disability progression as defined as evolution to a next step of Expanded Disability Status Scale (EDSS) score. However, the mean change in disability (final disability subtracted from the baseline) significantly favoured the treated group at 12 (effect size - 0.21, 95% confidence interval - 0.25 to -0.17) and 18 months (- 0.19, 95% confidence interval - 0.24 to - 0.14) but favoured the control group at 24 months (0.14, CI 0.07 to 0.21). We were unable to verify the efficacy of other schedules. Five patients died; sepsis and amenorrhea frequently occurred in treated patients (descriptive analysis).

AUTHORS' CONCLUSIONS: We were unable to achieve all of the objectives specified for the review. This review shows that the overall effect of CFX (administered as intensive schedule) in the treatment of progressive MS does not support its use in clinical practice.

Update of Cochrane Database Syst Rev. 2002;(4):CD002819.

What is your experience of diagnosis

The folks at MS Trust have made some videos concerning diagnosis with MS...As ever the MSers are the stars.

1. What was your experience of diagnosis? http://www.mstrust.org.uk/information/newly-diagnosed/what-happens-after-ms-diagnosis.jsp
 

2. What were your feelings when you were given a diagnosis of MS? 
http://www.mstrust.org.uk/information/newly-diagnosed/ms-and-your-feelings.jsp
and 

http://www.mstrust.org.uk/information/newly-diagnosed/life-with-ms.jsp#diagnosis

3. Did anything change after you were diagnosed with MS? http://www.mstrust.org.uk/information/newly-diagnosed/ms-and-life-choices.jsp#will-ms-affect-life-choices

4. How did family and friends respond to your diagnosis? http://www.mstrust.org.uk/information/newly-diagnosed/telling-people.jsp#family-friends

5. Did diagnosis with MS make any difference to your work or studying? 

http://www.mstrust.org.uk/information/newly-diagnosed/working-and-studying-with-ms.jsp#affect-work-education

6. How can someone live life to the full after diagnosis? http://www.mstrust.org.uk/information/newly-diagnosed/ms-and-life-choices.jsp#best-choices

and http://www.mstrust.org.uk/information/newly-diagnosed/living-well-with-ms.jsp#longer-term

7. What suggestions can you give about managing MS symptoms? http://www.mstrust.org.uk/information/newly-diagnosed/treating-symptoms.jsp#about-ms-treatments

8. What is the best way to learn about MS? http://www.mstrust.org.uk/information/newly-diagnosed/sources-of-information-and-support.jsp

9. What is it like to start on DMTs? http://www.mstrust.org.uk/information/newly-diagnosed/disease-modifying-treatments.jsp#can-i-have-dmts

Has the diagnosis affected how you feel about yourself? http://www.mstrust.org.uk/information/newly-diagnosed/ms-and-your-feelings.jsp#emotional
 

What is your advice to someone who is newly diagnosed? http://www.mstrust.org.uk/information/newly-diagnosed/life-with-ms.jsp#life
and 
http://www.mstrust.org.uk/information/newly-diagnosed/living-well-with-ms.jsp

To deplete or not to deplete that is the question?

Leucopaenia (low white blood cell) has become a hot topic of the past week, with the realisation that people who get leucopaenia (low white blood cell counts) are more at risk from infection and the dreaded PML. 

So now there  is a rush to stop the level of lymphopaenia from occurring, but one question is. Do we want our cake and eat it?Because we have to ask how do the MS-drugs stop MS?  

In many cases it is because of leucopaenia. This may be physical depletion of cells out of the body and the blood, in particular, such as with alemtuzumab or rituximab or it may be a functional leucopaenia, such as with Tysabri, where the cells are in the blood but because they cant get out of the blood they are powerless to deal with the infection within the brain.

I have heard it said that the efficacy of alemtuzumab or cladribine does not relate to the level of leucopaenia, which may be in part the case, but if you did not get leucopaenia would these drugs work...I really doubt it. 

They are integral to the mechanism of action, you need it to stop disease however if you maintain it, leucopenia will eventually lead to problems of immunosuppression which is the generation of infection and cancers....This is simple biology and we should not forget this you do not get one without the other if you maintain the treatment.
CD4 depletion was tried in MS and failed in MS. Does this mean that MS is not caused by the action of T cells? This is interesting when in animals CD4 T cell depletion inhibits about every known autoimmune disease, even if they are T or B cell autoimmunities?

CD4 treatment in humans was tried when AIDS was looming its ugly head and the Neuros were scarred that if you depleted the CD4 T cell number to low then you might get AIDS and so they only depleted about 50%. 

Yet the animal studies were based on an 80-90% depletion and depletion of  50% in animals would not be good enough to stop autoimmunity in animals, so why on earth would it work in humans? In my humble opinion the trial was doomed before it was even started!

This is not translation but throwing away good biology!

However, in animals we can say that depletion is absolutely required for action and the depletion within a few days of giving antibody is about 95% but within a few weeks it is about 60% so if you do a blood sample months after treatment as is the norm in human studies you do not get a picture of what has happened previously....maybe relating to the statements that leucopenia are not related to the mechanism of action, when it clearly is.

In contrast to the 60% depletion of anti-CD4  antibody, Alemtuzumab knocks T cells down by over 90% and inhibits relapsing MS. So the people are T cell lymphopaenic but if you look in the blood then the white cell population is filled with B cells within a few months, so they are not leucopenic on a total white cell count when they are if fact leucopaenic for certain cell types.

It is probable that PML involves loss of CD8 anti-viral responses as well as other immune arms. 

But now back to the T cells. Are they not involved in MS?...if they are not, hundreds of people are wasting their time, including the EAEers (No snarky comments please!). 

However it looks like the effective treatments in MS cause depletion of B cells like anti-CD20.....The doubting immunologists state that this is because anti CD20 takes out a subset of T cells and they are the problem. 

This makes the point that you have to know what is interesting when you define leucopaenia. Just counting cell numbers may be meaning less. If it is those few T cells that are critical and their loss makes no difference on leucopaenia.

With Alemtuzumab there are massive reductions in T cells in including T reg cells, is this why autoimmunity comes back? Well the T reg to T cell ratio may favour more T regs but the T reg to B cell numbers are dwarfed. At ACTRIMS2014 it was shown that CD19, CD5+ B cells massively proliferate after Alemtuzumab....Is this why you get B cell autoimmunities? In contrast the CD19+, CD27+ memory B cells were flatlined...is this why MS is halted? 

I don't know but the point I am making is that the you need to know what you are looking for when you are talking about leucopaenia to know if it is functionally relevant or not. Without that ,looking for a  blanket leucopenia may be not sufficiently meaningful.

Monday, 27 October 2014

More Epitopes to induce EAE and MS?

Novel pathogenic epitopes of myelin oligodendrocyte glycoprotein induce experimental autoimmune encephalomyelitis in C57BL/6 mice. Delarasse C, Smith P, Baker D, Amor S. Immunology. 2013 Dec;140(4):456-64. doi: 10.1111/imm.12155.
Myelin oligodendrocyte glycoprotein (MOG), a minor protein of the central nervous system myelin, is recognized as a potential target in multiple sclerosis and neuromyelitis optica. The extracellular domain of MOG is commonly used in a wide range of mouse strains and other animals to induce experimental autoimmune encephalomyelitis (EAE), an autoimmune animal model of multiple sclerosis, because it is a target for antibody-mediated attack. Previous studies, using selected peptides, have indicated that MOG(35-55) peptide is an encephalitogenic epitope in C57BL/6 (H-2(b)) mice. A more systematic analysis of both T-cell and B-cell responses following immunization of C57BL/6 mice with either recombinant extracellular mouse MOG protein (1-116) or with overlapping peptides spanning the whole sequence of MOG, before assessment of responses to 15 mer and 23 mer peptides was undertaken. The studies identified T-cell responses within the MOG(35-55) (extracellular domain) but also two new immunogenic and encephalitogenic T-cell epitopes within residues MOG(113-127), MOG(120-134) (localized in the transmembrane region) and MOG(183-197) (in the second hydrophobic MOG domain). In addition, residue MOG(113-127) was found to be a B-cell epitope, suggesting that this may be a useful adjunct for the induction of EAE as well as for immunological studies in C57BL/6 mice, which are increasingly being used to study immune function through the use of transgenic and gene knockout technology.

Immunodominant T-cell epitopes of MOG reside in its transmembrane and cytoplasmic domains inEAE.Shetty A, Gupta SG, Varrin-Doyer M, Weber MS, Prod'homme T, Molnarfi N, Ji N, Nelson PA, Patarroyo JC, Schulze-Topphoff U, Fogal SE, Forsthuber T, Sobel RA, Bernard CC, Slavin AJ, Zamvil SS. Neurol Neuroimmunol Neuroinflamm. 2014 Aug 14;1(2):e22. doi: 10.1212/NXI.0000000000000022. eCollection 2014 Aug.

OBJECTIVE:Studies evaluating T-cell recognition of myelin oligodendrocyte glycoprotein (MOG) in multiple sclerosis (MS) and its model, experimental autoimmune encephalomyelitis (EAE), have focused mostly on its 117 amino acid (aa) extracellular domain, especially peptide (p) 35-55. We characterized T-cell responses to the entire 218 aa MOG sequence, including its transmembrane and cytoplasmic domains.
METHODS:T-cell recognition in mice was examined using overlapping peptides and intact full-length mouse MOG. EAE was evaluated by peptide immunization and by adoptive transfer of MOG epitope-specific T cells. Frequency of epitope-specific T cells was examined by ELISPOT.
RESULTS:Three T-cell determinants of MOG were discovered in its transmembrane and cytoplasmic domains, p119-132, p181-195, and p186-200. Transmembrane MOG p119-132 induced clinical EAE, CNS inflammation, and demyelination as potently as p35-55 in C57BL/6 mice and other H-2(b) strains. p119-128 contained its minimal encephalitogenic epitope. p119-132 did not cause disease in EAE-susceptible non-H-2(b) strains, including Biozzi, NOD, and PL/J. MOG p119-132-specific T cells produced Th1 and Th17 cytokines and transferred EAE to wild-type recipient mice. After immunization with full-length MOG, a significantly higher frequency of MOG-reactive T cells responded to p119-132 than to p35-55, demonstrating that p119-132 is an immunodominant encephalitogenic epitope. MOG p181-195 did not cause EAE, and MOG p181-195-specific T cells could not transfer EAE into wild-type or highly susceptible T- and B-cell-deficient mice.
CONCLUSIONS:Transmembrane and cytoplasmic domains of MOG contain immunodominant T-cell epitopes in EAE. A CNS autoantigen can also contain nonpathogenic stimulatory T-cell epitopes. Recognition that a myelin antigen contains multiple encephalitogenic and nonencephalitogenic determinants may have implications for therapeutic development in MS.


Always good to see that people can repeat our work.

This paper demonstrates that there are many epitopes (bits of the protein) in myelin that can induce T cell proliferation but they don't necessarily induce disease in animals, as we have shown numerous times for myelin and non-myelin antigens. 

Therefore studies based on simple proliferation assays of T cell responses in humans, as a prelude to doing trials may pick the wrong candidates and indeed many of the pathogenic epitopes in animals that we have found don't give good proliferative responses, so this is probably the wrong way to select candidates peptides for antigen-specific treatment studies.

The epitopes that are recognised by the Mice can also be recognised by some MSers. Does this mean it causes disease? 
 
Varrin-Doyer M, Shetty A, Spencer CM, Schulze-Topphoff U, Weber MS, Bernard CC, Forsthuber T, Cree BA, Slavin AJ, Zamvil SS.MOG transmembrane and cytoplasmic domains contain highly stimulatory T-cell epitopes in MS. Neurol Neuroimmunol Neuroinflamm. 2014;1(2):e20. doi: 10.1212/NXI.0000000000000020. eCollection 2014 Aug.

OBJECTIVE: Recently, we reported that the 218 amino acid murine full-length myelin oligodendrocyte glycoprotein (MOG) contains novel T-cell epitopes p119-132, p181-195, and p186-200, located within its transmembrane and cytoplasmic domains, and that p119-132 is its immunodominant encephalitogenic T-cell epitope in mice. Here, we investigated whether the corresponding human MOG sequences contain T-cell epitopes in patients with multiple sclerosis (MS) and healthy controls (HC).
METHODS: Peripheral blood T cells from patients with MS and HC were examined for proliferation to MOG p119-130, p181-195, p186-200, and p35-55 by fluorescence-activated cell sorting analysis using carboxylfluorescein diacetate succinimidyl ester dilution assay. Intracellular production of proinflammatory cytokines was analyzed by flow cytometry.
RESULTS: MOG p119-130, p181-195, and p186-200 elicited significantly greater T-cell responses than p35-55 in patients with MS. T cells from patients with MS proliferated significantly more strongly to MOG p119-130 and p186-200 than did T cells from HC. Further, MOG p119-130-specific T cells exhibited Th17 polarization, suggesting this T-cell epitope may be relevant to MS pathogenesis.
CONCLUSIONS: Transmembrane and cytoplasmic MOG domains contain potent T-cell epitopes in MS. Recognition of these determinants is important when evaluating T-cell responses to MOG in MS and may have implications for development of myelin antigen-based therapeutics.

Emoji Research

It seems that scientists are pretty rubbish in describing their work in language that the average person can read.

So some are turning to the use of Emoji and using Emoticons to get across their message. 

These are characters like the smiley face and people are using them to replace big words like "mouse" with pictures of mice. There is a even a Emoji Dictionary.

Should we change the blog...What do you think?

However, one reason that English is a good science language....(a) Many people round the world speak it and (b) it has lots of words to describe things...unlike the Emoji Dictionary.

I think it is better to treat people like adults :-)

Sunday, 26 October 2014

Remyelination Drug is Safe in Humans

Tran JQ, Rana J, Barkhof F, Melamed I, Gevorkyan H, Wattjes MP, de Jong R, Brosofsky K, Ray S, Xu L, Zhao J, Parr E, Cadavid D.
Randomized phase I trials of the safety/tolerability of anti-LINGO-1 monoclonal antibody BIIB033. Neurol Neuroimmunol Neuroinflamm. 2014;1(2):e18. doi: 10.1212/NXI.0000000000000018. eCollection 2014 Aug.

OBJECTIVE:  To evaluate the safety, tolerability, and pharmacokinetics (PK) of BIIB033 (anti-LINGO-1 monoclonal antibody) in healthy volunteers and participants with multiple sclerosis (MS).
METHODS: In 2 separate randomized, placebo-controlled studies, single ascending doses (SAD; 0.1-100 mg/kg) of BIIB033 or placebo were administered via IV infusion or subcutaneous injection to 72 healthy volunteers, and multiple ascending doses (MAD; 0.3-100 mg/kg; 2 doses separated by 14 days) of BIIB033 or placebo were administered via IV infusion to 47 participants with relapsing-remitting or secondary progressive MS. Safety assessments included adverse event (AE) monitoring, neurologic examinations, conventional and nonconventional MRI, EEG, optical coherence tomography, retinal examinations, and evoked potentials. Serum and CSF PK as well as the immunogenicity of BIIB033 were also evaluated.
RESULTS: All 72 healthy volunteers and 47 participants with MS were included in the safety analyses. BIIB033 infusions were well tolerated. The frequency of AEs was similar between BIIB033 and placebo. There were no serious AEs or deaths. No clinically significant changes in any of the safety measures were observed. BIIB033 PK was similar between healthy volunteers and participants with MS. Doses of ≥10 mg/kg resulted in BIIB033 concentrations similar to or higher than the concentration associated with 90% of the maximum remyelination effect in rat remyelination studies. The incidence of anti-drug antibody production was low.
CONCLUSIONS: The emerging safety, tolerability, and PK of BIIB033 support advancing BIIB033 into phase II clinical development as a potential treatment for CNS demyelination disorders.
CLASSIFICATION OF EVIDENCE: This study provides Class I evidence that BIIB033 is well tolerated and safe (serious adverse event rate 0%, 95% confidence interval 0-7.6%)
.

Anti-LINGO-1 is antibody that targets LINGO-1 and this has been associated with promoting remyelination and possibly it cause also promote nerve plasticity (regrowth of nerve pathways to maintian nerve function in damaged nerve pathways). This is the safety study showing that the treatment is safe. The question is will enough antibody reach the CNS to cause remyelination. The trials in MS are underway.

Saturday, 25 October 2014

ClinicSpeak: exercise and depression

How effective is exercise as an anti-depressant in MS? #MSBlog #MSResearch #ClinicSpeak

"The meta-analysis below does not show a clear link between exercise and a reduction in depression in MSers. Too few studies that are underpowered and/or poorly designed. Despite this I recommend that all MSers should try and exercise. There is good evidence from outside the field of MS that it works and it is an important component of any programme that targets brain health. Regular aerobic exercise delays the onset of Alzheimer's disease and may slow down the progression of MS. Exercise has numerous positive effects in the brain; increasing so called endorphins (one of the brain's antidepressants) and growth factors that promote neuronal survival (insulin-like growth factor-1 or IGF-1). I know many of you very disabled and are not capable of ordinary exercise; if this is the case you should ask to be referred to a neuro-physiotherapist who can help devise an exercise programme for you. You will be surprised what a difference exercise can make."

"If haven't read my previous post on brain health, I would urge you to read it now."



BACKGROUND AND PURPOSE:The purpose of this study was to perform a systematic review of the literature on the effects of exercise on depressive symptoms in MSers, as well as to apply meta-analytical procedures to the results.

METHODS: A systematic search covering eight databases was conducted. The included studies were randomized controlled trials applied to people with definite MS who completed a structured exercise intervention which were compared to any comparator, including other forms of exercise. The outcomes included a primary measure of depression/depressive symptoms or an instrument with a clearly defined depression subscale.

RESULTS: Fifteen randomized controlled trial studies were identified including a total of 331 exercising subjects and 260 controls. The average Physiotherapy Evidence Database (PEDro) score was 5.6 ± 1.3 points. Only one study applied depressive symptoms as the primary outcome. Four studies showed positive effects of exercise on depressive symptoms. An in-depth analysis of the studies revealed that the baseline level of depressive symptoms, patient disability level, choice of depression instrument and exercise intensity may influence the results. The meta-analysis included 12 studies reflecting a total of 476 subjects. The standardized mean difference across studies was g = -0.37, 95% confidence interval (-0.56; -0.17), and the null hypothesis of homogeneity within the sample could not be rejected (Q = 12.05, df = 11, P = 0.36).

DISCUSSION: Exercise may be a potential treatment to prevent or reduce depressive symptoms in individuals with MS, but existing studies do not allow solid conclusions. Future well-designed studies evaluating the effects of exercise on depressive symptoms and major depression disorder in MS are highly warranted.

How does Gilenya work and avoid PML risks?

Mehling M, Brinkmann V, Antel J, Bar-Or A, Goebels N, Vedrine C, Kristofic C, Kuhle J, Lindberg RL, Kappos L.FTY720 therapy exerts differential effects on T cell subsets in multiple sclerosis. Neurology. 2008 Oct 14;71(16):1261-7.

BACKGROUND:  The oral immunomodulator FTY720 has shown efficacy in patients with relapsing multiple sclerosis (MS). FTY720 functionally antagonizes sphingosine 1-phosphate receptor-1 (S1P1) on T cells and consequently inhibits S1P/S1P1-dependent lymphocyte egress from secondary lymphoid organs. Little is known about the phenotype and function of T cells remaining in peripheral blood during long-term FTY720 treatment.
METHODS:T cells from FTY720-treated, interferon-beta (IFNbeta)-treated and untreated patients with MS, and healthy donors (HD) were analyzed with respect to T cell subpopulation composition, proliferation, and cytokine production.
RESULTS:In FTY720-treated patients (n = 16), peripheral blood CD4+ and CD8+ T cell counts were reduced by approximately 80% and 60% when compared to the other groups (IFN beta: n = 7; untreated: n = 5; HD: n = 10). This related to selective reduction of naive (CCR7+CD45RA+) and central memory (CCR7+CD45RA-) T cells (TCM), and resulted in a relative increase of peripheral effector memory (CCR7-CD45RA- [TEM] and CCR7-CD45RA+ [TEMRA]) T cells. The remaining blood T cell populations displayed a reduced potential to secrete IL-2 and to proliferate in vitro, but rapidly produced interferon-gamma upon reactivation, confirming a functional TEM/TEMRA phenotype. Neither FTY720 nor FTY720-P directly suppressed proliferation or cytokine production by T cells.
CONCLUSION:Therapeutic dosing of FTY720 reduces naïve T cells and TCM, but not TEM, in blood, without affecting T cell function. This is presumably because naive T cells and TCM express the homing receptor CCR7, allowing recirculation to secondary lymphoid tissues on a regular basis and, thus, trapping of the cells by FTY720 in lymph nodes.



Johnson TA, Lapierre Y, Bar-Or A, Antel JP. Distinct properties of circulating CD8+ T cells in FTY720-treated patients with multiple sclerosis. Arch Neurol. 2010; 67(12):1449-55. doi: 10.1001/archneurol.2010.312 
OBJECTIVE:To define the capacity of peripheral blood CD8(+) T cells from patients with multiple sclerosis (MS) receiving Gilenya/fingolimod (FTY720) to migrate in response to chemokines that contribute to trafficking into the central nervous system.
DESIGN:Peripheral blood T cells of FTY720-treated patients with MS (MS-FTY) are mainly CD8(+) CCR7⁻ effector memory cells as CCR7(+) T cells are inhibited from exiting from secondary lymph nodes. Migration of CD8(+) T cells from MS-FTY patients and untreated donors to chemokines CXCL12 and CCL2 was assayed in vitro. Expression of CCL2 receptor (CCR2), CCR7, CD28, and CD27 on CD8(+) T cells was determined by flow cytometry.
RESULTS:In vitro addition of active (phosphorylated) FTY720 increased migration of CD8(+) T cells from untreated patients to CXCL12 and CCL2. The CD8(+) or CD8(+) CCR7⁻ T cells from MS-FTY patients migrated less to CXCL12 and CCL2 compared with those from untreated donors. The proportion of CD8(+) CCR7⁻ cells that express the CCL2 chemokine receptor, CCR2, was significantly reduced in the MS-FTY group. The CD8(+) CCR7⁻ cells from the MS-FTY patients were enriched with CD27⁻ CD28⁻ (late effector) memory cells, a population with reduced expression of CCR2 compared with early (CD27(+) CD28(+)) effector memory cells.
CONCLUSIONS:Therapy with FTY720 results in a subset of CD8(+) T cells with distinct functional migratory properties dominating the peripheral circulation. The expected forthcoming use of FTY720 as a sustained therapy for MS will clarify how this redistribution of lymphocyte populations affects the overall process of immune surveillance.
 
Mehling M, Lindberg R, Raulf F, Kuhle J, Hess C, Kappos L, Brinkmann V.Th17 central memory T cells are reduced by FTY720 in patients with multiple sclerosis. Neurology. 2010 Aug 3;75(5):403-10. doi: 10.1212/WNL.0b013e3181ebdd64.
OBJECTIVE: FTY720 is a sphingosine 1-phosphate (S1P) receptor modulator that showed efficacy in phase II and III clinical trials in patients with multiple sclerosis (MS). FTY720 inhibits lymphocyte egress from secondary lymphoid organs into the peripheral circulation, thereby reducing the number of circulating naïve and central memory T cells, but not effector memory T cells in blood. Little is known to which of these memory T-cell subsets interleukin 17 (IL-17)-producing T cells (Th17 cells) belong, which are considered to be key mediators of inflammation in MS, and how they are affected by treatment with FTY720. In this study, we determined the phenotype and frequency of Th17 cells in blood of untreated, FTY720-treated, and interferon-beta (IFNbeta)-treated patients with MS and healthy donors.
METHODS:In a prospective observational study, circulating T cells were phenotypically characterized and Th17 cells enumerated in T-cell subsets ex vivo. Production of IL-17 upon activation and expression of the Th17-specific transcription factor RORC2 was assessed in vitro.
RESULTS:Th17 cells were found primarily within central memory T cells in all study populations. FTY720 treatment reduced blood central memory T cells, including RORC2+ and IL-17-producing T cells, by >90%. FTY720 did not per se affect IL-17 production when added to activated T cells in vitro.
CONCLUSION:Phenotypic Th17 cells are defined by a central memory T-cell phenotype. FTY720 reduces these Th17 cells in blood. This is presumably because central memory T cells are retained by FTY720 in secondary lymphoid organs.
PML has been rearing its head again. It is the nemesis of Tysabri but as about 50% to 60% of MSers are infected with the virus that causes PML and it has to be a risk factor for anybody who is immunosuppressed. 
 
Tysabri stops white bloodcells gettinginto the brain and so it cannot eliminate JC virus that maygetinto brain cells. If you don't have white blood cells in the blood it is also going to be a risk. 
 
So why hasn't their being loads of PML in people taking interferon beta and copaxone? I suspect they are not very immunosuppressive.
 
 So what about Alemtuzumab and Gilenya? Will they cause PML?
 
Quite possibly it is a numbers game. As more people use the drug for longer then the chances of this rare event increases. 
 
However, PML appears to occur with long term immunosuppression and leucopaenia (Loss of white lood cells from the blood). 
 
Whilst Alemtuzumab causes such long-term immunosuppression of the T cell response, it has to be said that Alemtuzumab will be out of the system within a month or so. After that people are drug free and therefore anti-viral cells can expand and do their job of getting rid of virus. 
 
However with Gilenya you take it every day and it effectively empties the blood of white blood cells because they get stuck in the lymph glands and so shouldn't this have the risk seen with Tysabri?
 
There has been enough time for PML to have reared its head. It has of course but most of these have been following tysabri treatment.
 
However, it has to repeated that it is thought that Gilenya is not a blanket inhibitor of T cell function. It blocks naive (T cells that have not yet been stimulated by their target) and central memory cells (which is suggested to contain the population of cells that cause MS. It also hits a subset of memory B cells too) but not the Effector T cell population. It is this population that it has been suggested to contain viral immunity and so may give some protection  against the JC virus. However of course this is not absolute as there have been problems of viral infections such as Herpes in people taking Gilenya but this bit of biology may contribute to the pausity so far of PML in people taking Gilenya.
 
CoI: None   ProfG: multiple

Friday, 24 October 2014

What remyelinates

Xing YL, Röth PT, Stratton JA, Chuang BH, Danne J, Ellis SL, Ng SW, Kilpatrick TJ, Merson TD. Adult neural precursor cells from the subventricular zone contribute significantly to oligodendrocyte regeneration and remyelination. J Neurosci. 2014 ;34(42):14128-46.

Parenchymal oligodendrocyte progenitor cells (pOPCs) are considered the principal cell type responsible for oligodendrogenesis and remyelinaton in demyelinating diseases. Recent studies have demonstrated that neural precursor cells (NPCs) from the adult subventricular zone (SVZ) can also generate new oligodendrocytes after demyelination. However, the relative contribution of NPCs versus pOPCs to remyelination is unknown. 


We used in vivo genetic fate mapping to assess the behavior of each progenitor type within the corpus callosi (CCs) of mice subjected to cuprizone-induced demyelination. Nestin-CreER(T2) and Pdgfra-CreER(T2) transgenic mice were crossed with fluorescent Cre reporter strains to map the fate of NPCs and pOPCs respectively. In cuprizone-challenged mice, substantial numbers of NPCs migrated into the demyelinated CC and contributed to oligodendrogenesis. This capacity was most prominent in rostral regions adjacent to the SVZ where NPC-derived oligodendrocytes significantly outnumbered those generated from pOPCs. Sixty-two percent of all nodes of Ranvier in this region were flanked by at least one paranode generated from an NPC-derived oligodendrocyte. Remarkably, g-ratios (ratio of the axon diameter to the diameter of the axon plus myelin sheath) of myelinated axons in regions subject to significant NPC-derived remyelination were equivalent to those of unchallenged controls, and immunoelectron microscopy revealed that NPC-derived myelin was significantly thicker than that generated by pOPCs, regardless of axonal caliber. We also demonstrate that a reduced efficiency of remyelination in the caudal CC was associated with long-term impairment in the maturation of oligodendrogenic NPCs but only transient delay in pOPC differentiation. Collectively, our data define a major distinct role for NPCs in remyelination, identifying them as a key target for enhancing myelin repair in demyelinating diseases.

You can all read the post. It is typically stated that remyelination produces thinner myelin so the D above would be less and the g would therefore be bigger. In this instance there was normal myelination

ClinicSpeak: PML and dimethyl fumarate (Tecfidera)

How should we deal with the PML risk in patients on Tecfidera? #ClinicSpeak #MSBlog #MSResearch

"Progressive multifocal leukoencephalopathy or PML is classed as an opportunistic infection and typically occurs in patients who are immunosuppressed as a result of cancers, in particular haematological malignancies, immunosuppression from medication, or specific diseases such as HIV that are associated with immune suppression."

"The fact that Biogen-Idec reported a case of PML on their formulation of dimethyl fumarate or DMF (Tecfidera) two days ago appears to have triggered a panic response. My email inbox is full of queries from anxious patients and colleagues about what we should do."

"I have noted a spike in Google Trends when using the search terms ‘Tecfidera and PML’. The questions I have been asked are:

1. Should we treat the risk of PML on DMF in the same way do the risk on natalizumab?

Obviously not; we need to take a step back and think rationally about things. DMF has been around for decades as a treatment for psoriasis. If DMF was a major risk factor for PML we would have seen far more cases in patients with psoriasis. I have posted on the latter before and we got Professor Gold, who looked after one of the psoriasis PML cases to comment as well. In summary and to the best of my knowledge there have been 5 PML reports in patients with psoriasis on DMF. All but one of the cases had been on multiple immunosuppressive therapies that are known risk factors for PML. The one patient who developed PML on DMF monotherapy has a very low lymphocyte count for several years (5 years) before developing PML. The latter seems to be the same as the reported patient with MS. This patient had been on DMF as part of the clinical trial programme for 4-and-a-half years and had a persistent lymphopaenia for 3-years before developing PML. The questions I have asked Biogen-Idec to answer are: (1) how severe was that lymphopaenia?; (2) why was he/she left on DMF; (3) when DMF was stopped did the lymphocyte counts recover; (4) were there any other risk factors for PML, for example previous use of immunosuppressants? Until we have more information it would be foolish to speculate. What is clear is that PML on DMF is likely to be rare considering the psoriasis data set. The one proviso is that the dermatologists tend not to use DMF as a continuous long-term therapy in psoriasis so the situation in MS may be different. Therefore in the short-term what we need to do is be more vigilant about lymphopaenia and if someone on DMF develops a persistently low lymphocyte count the drug will need to be stopped. Until we get more data I would suggest anyone with a lymphocyte count less than 800/mm3, or 0.8x10**9/L, takes a drug holiday for several weeks until their lymphocyte counts recover above 1200/mm3, or 1.2x10**9/L; if the lymphocyte counts don’t recover, or drop below this proposed threshold on restarting DMF the drug will need to be stopped. Please note that a threshold or cut-off of 800 (WHO grade 1/2 lymphopaenia boundary) is conservative and we may be able in the future to set the cut-off at 500 (WHO grade 2/3 lymphopaenia boundary). Setting cut-offs like this will need to be data driven and does not take into account lymphocyte function."

"We will also need to be more vigilant about screening for lymphopenia in patients on DMF. The EMA summary of product characteristics states: ‘Tecfidera may decrease lymphocyte counts (see section 4.8). Tecfidera has not beenstudied in patients with pre-existing low lymphocyte counts and caution shouldbe exercised when treating these patients. Prior to initiating treatment withTecfidera, a recent complete blood count (i.e. within 6 months) should beavailable. Assessments of complete bloodcounts are also recommended after 6 months of treatment and every 6 to 12months thereafter and as clinically indicated’. I would suggest that we now institute 6 monthly monitoring as we do for patients on interferon-beta."

2. Should we stop DMF in patients who are JCV positive?

"Clearly not. The main risk factor for PML appears to be lymphopaenia. Therefore if you are JCV positive on DMF and have a normal lymphocyte count there is probably nothing to worry about. There is some data from the psoriasis literature suggesting that DMF may have a mode of action in addition to lymphopaenia, that may add to the PML risk; it seems to interfere with adhesion of leukocytes to blood vessels and reduce trafficking of cells. This situation is not too dissimilar to natalizumab in which we know that the PML risk is linked to the mode of action of natalizumab, i.e. its stops trafficking of lymphocytes into the brain and reduces immune surveillance for infections."

3. Should we start routine JCV testing in patients about to start DMF or who are on DMF?

"No I don’t think this is necessary. The only situation I envisage this happening in, is if someone is doing well on DMF and has a lymphopaenia and wants to stay on the drug. Being JCV seronegative may give this person and their clinician more confidence in leaving them on DMF."



4. Should we not start someone on DMF if they already have a lymphopaenia?

"This will depend on the cause of the lymphopaenia. If for example they are switching from fingolimod, that causes a reversible lymphopaenia, it would seem reasonable to check lymphocyte counts after 8 weeks to make sure they have recovered. If the cause of lymphopaenia is due to previous immunosuppression, for example secondary to corticosteroids, cladribine, alemtuzumab, mitoxantrone, teriflunomide, etc. I would be more careful. In this situation a decision will need to be made after considering the level of lymphopaenia and how active the patient's MS is. This may be one situation were a JCV serology may help. Please note that prior immunosuppressive therapies is in itself a major risk factor for PML ; therefore if the patient is JCV seropositive you will need to be more careful."

5. Is there something specific about DMF that causes PML?

"As I have alluded to above there DMF may affect cell trafficking into the brain and spinal cord that can increase PML risk independent to lymphopaenia. We need more data on this in relation to MS. Please note that almost every drug that affects the immune system has been associated with cases of PML."

"We mustn’t get distracted from the fact that this is a personal tragedy. Someone with MS has died as a direct result of a treatment for MS. My condolences go out to the family and friends of this patient. From my perspective as an MSologist this complication may have been preventable, which is the main reason for this post. We must also not forget that this patient participated in the DMF clinical trial programme and without his/her participation other MSers would not be benefiting from DMF. I suggest we all pause to reflect on this tragedy.“


CoI: multiple

Detecting JC virus

Lanzillo R, Liuzzi R, Vallefuoco L, Moccia M, Amato L, Vacca G, Vacchiano V, Portella G, Brescia Morra V. JC virus antibody index in natalizumab-treated patients: correlations with John Cunningham virus DNA and C-reactive protein level. Ther Clin Risk Manag. 2014;10:807-14. 

Natalizumab-treated patients have a higher risk of developing progressive multifocal leukoencephalopathy. Exposure to John Cunningham virus (JCV) is a prerequisite for PML (progressive multifocal leukoencephalopathy). To assess JCV exposure in multiple sclerosis patients, we performed a serological examination, obtained the antibody index, performed real-time polymerase chain reaction (PCR) to detect JCV DNA in plasma and urine, and investigated the role of ultrasensitive C-reactive protein (usCRP) as a possible biological marker of JCV reactivation. We retrospectively analyzed consecutive natalizumab-treated multiple sclerosis patients who underwent a JCV antibody test through a two-step enzyme-linked immunosorbent assay (STRATIFY test) to the measure of serum usCRP levels, and to perform blood and urine JCV PCR. The studied cohort included 97 relapsing-remitting patients (60 women). Fifty-two patients (53.6%) tested positive for anti-JCV antibodies. PCR showed JCV DNA in the urine of 30 out of 83 (36.1%) patients and 28 out of 44 seropositive patients (63.6%), with a 6.7% false-negative rate for the STRATIFY test. Normalized optical density values were higher in urinary JCV DNA-positive patients (P<0.0001). Interestingly, the level of usCRP was higher in urinary JCV DNA-positive patients and correlated to the number of DNA copies in urine (P=0.028). As expected, patients' age correlated with JCV seropositivity and with JC viruria (P=0.02 and P=0.001, respectively). JC viruria was significantly correlated with a high JCV antibody index and high serum usCRP levels. We suggest that PCR and usCRP might be useful as markers of JCV reactivation, and that patients should be monitored between STRATIFY assessments.

C-reactive protein (CRP) is an annular (ring-shaped), pentameric protein found in the blood plasma, the levels of which rise in response to inflammation (i.e., C-reactive protein is an acute-phase protein). Its physiological role is to bind tophosphocholine expressed on the surface of dead or dying cells (and some types of bacteria) in order to activate the complement system

CRP is synthesized by the liver in response to factors released by macrophages and fat cells. C-reactive protein is a pattern recognition receptor (PRR). These are proteins expressed by cells of the innate immune system to identify pathogen-associated molecular patterns (PAMPs), which are associated with microbial pathogens or cellular stress, as well as damage-associated molecular patterns (DAMPs), which are associated with cell components released during cell damage due to infection. In this study they assayed the presence of c reactive protein with ultra sensitive measurement to link this to infection with JC virus. The used polymerase chain reaction to detect the virus. PCR is a technique where you amplify DNA from low levels to high levels so you can see if it is present.

If you have high levels of  Viral DNA you are much more likely to be  Antibody positive and this occurs in about 50% of people and is more robust that looking for viral DNA however there are some false negatives.