Tuesday, 29 November 2016

Is there life still left in 1st line injectables? An assessment of cognition

Neurol Sci. 2016 Nov 24. [Epub ahead of print]

Cognitive dysfunction in patients with multiple sclerosis treated with first-line disease-modifying therapy: a multi-center, controlled study using the BICAMS battery.

Cinar BP, Kösehasanoğulları G, Yigit P, Ozakbas S.

Abstract


Multiple sclerosis (MS) can impair cognitive functions even in the early stages. The Brief International Cognitive Assessment for Multiple Sclerosis (BICAMS) battery is very short and highly sensitive and can be used to evaluate cognitive status in the disease. Several clinical trials have shown beneficial effects of disease-modifying drugs (DMDs) on long-term cognitive measures which may even reduce cognitive deficits in MS patients. Relapsing remitting MS patients using DMDs were enrolled in the study and monitored for 12 months. BICAMS and the Expanded Disability Status Scale were applied to the study group. We evaluated and monitored 161 newly diagnosed cases of definite MS by the end of the trial. 110 patients (68.2%) were female. One hundred and two healthy subjects (female to male ratio 68:34) were enrolled into the study. MS patients were categorized into three DMT groups: IFNB1-a SC, IFNB1-b, and GA. Mean scores of all three cognitive tests (SDMT, BVMT-R, and CVLT-II) were significantly higher in the control group than in the MS patients. The number of cognitively impaired patients decreased from 31.7 to 21.7% on the basis of CVLT (p = 0.024), and 42 (26.1%) to 30 (18.6%) on the basis of BVMT-R at month 12. A significant difference was determined in terms of cognitive status between MS patients using both IFNB and GA and the healthy control group. Ours is the first study to compare IFNB and GA in terms of evaluating cognitive involvement and to use the BICAMS battery in monitoring treatment.

Figure: Comparison of percentages of cognitively impaired patients at baseline and at the end of study.

Realistically speaking, most neurologists have consigned the older 1st line injectables to the back of the sock drawer. This may be the effect of skilful marketing, but I believe on balance it is probably straight forward natural evolution. Like wrinkles on your face, MS treatments are also not resistant to the test of time. But can we give them an extra lease of life? This is what Cinar et al. propose, and use cognitive decline to make their case. Cognitive decline is a hidden threat in MS; very much overlooked in MS clinical trials, but vital to PwMS.

They studied 161 PwMS (on IFNb1a, IFNb1b, GA), with an average age of 30, disease duration of 2 years, and in education for 13 years. The mean SDMT (single digit modalities test) was 12.3 points higher in controls than in PwMS; even at this relatively young age and short duration of disease. The score, however, improved in all PwMS over the 12 months compared to baseline (see above figure), indicating that injectables have a beneficial impact on cognitive status. They did not find any difference between the three different treatments studied.

So it would appear that 1st line injectables still have some fight left in them. How would they then compare to the newer, and more highly active treatments, as far as cognition is concerned? Would they be better or simply the same? It is important to remember that at the end of the game, both the king and the pawn return to the same box.

2 comments:

  1. I think the first generation drugs are done, we should enforce the obsolescence on these tools so that big pharma will build a better mousetrap. Make room in your attics for these drugs beside the Super NES and game boy. Those are technology from the same era.

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    Replies
    1. They may still be an option for de-escalation following induction treatment...mind you, this is not the way they're licensed for use.

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