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Continuous treatment reduces risk of confirmed disability progression in MS
STOCKHOLM – (CDP), according to an investigation presented at the annual congress of the European Committee for Treatment and Research in Multiple Sclerosis.
Using several confirmation points for Expanded Disability Status Scale (EDSS) progression (e.g., 12 months and 24 months), researchers detected a clear gradient of treatment effect. Identification of the most reliable outcome definitions will require further investigations, they said.
“The ultimate goal of MS treatment is the prevention of long-term disability accumulation,” said Giuseppe Lucisano, a biostatistician at the Center for Outcomes Research and Clinical Epidemiology in Pescara, Italy. “Continuous DMT exposure can impact long-term disability accumulation in MS, but it has not been definitively demonstrated yet.”
Registries and clinical databases provide the opportunity to collect longitudinal data for treated and untreated patients as a means of investigating questions such as this one, the researchers said. The Danish, Italian, and Swedish national MS registries, MSBase, and the Observatoire of MS (OFSEP) merged their data in the Big Multiple Sclerosis Data (BMSD) Network, which includes approximately 150,000 patients and more than 470,000 EDSS evaluations. The result is a large dataset suitable for long-term longitudinal studies.
Mr. Lucisano and colleagues sought to examine the long-term effect of DMTs on CDP and irreversible disability milestones (i.e., EDSS scores of 4 and 6) in relapsing-remitting MS. The researchers used marginal structural proportional models, a novel technique that enables them to correct modeling for confounders that vary with time in longitudinal observational studies. Such confounders include treatment switches, on-treatment relapses, and treatment gaps.
The investigators selected patients with 10 or more years’ follow-up and one or more EDSS score evaluations per year from the BMSD pooled cohort. Using marginal structural proportional models, the investigators evaluated cumulative hazards of 3-, 12- and 24-month CDP (i.e., CDP3, CDP12, CDP24) events in 6-month periods. They created stabilized inverse probability of treatment weights (IPTWs) at each 6-month period using survival models according to treatment status (i.e., treated versus untreated). Treatment status was assigned for each patient according to the percentage of time that he or she spent receiving DMT in each 6-month period. A patient who received treatment for 70% or more of the period studied was considered treated; patients who did not meet this threshold were considered untreated. The weights were calculated on the basis of sex, age, occurrence of relapse, EDSS score, and registry source. Finally, the researchers used Cox regression models estimating the effect of DMTs on the risk of reaching CDP3, CDP12, and CDP24, adjusted by the IPTWs, to compare cohorts that remained treated or untreated throughout follow-up.
The investigators identified a cohort of 15,602 patients with relapsing-remitting MS, and this group had 312,040 EDSS score evaluations. Approximately 28% of patients were male. Median age at disease onset was 28.3 years, and median disease duration was 18.7 years. Median follow-up duration was 13.8 years.
During follow-up, 43.3% of patients had CDP3, 27.7% had CDP12, and 14.4% had CDP24 events. In addition, 23.6% of patients reached an EDSS score of 4, and 11.2% reached an EDSS score of 6.
Cox models adjusted by IPTW demonstrated increasing positive evidence of the effect of cumulative treatment exposure, compared with cumulative untreated epochs, according to the length of confirmation time used for defining the CDP. The investigators did not observe an effect of treatment on the probability of reaching CDP3 (hazard ratio [HR], 1.02), but treatment had a protective effect on CDP12 (HR, 0.90) and CDP24 (HR, 0.65) endpoints. During treated epochs, the HR of EDSS 4 was 0.89, and the HR of EDSS 6 was 0.86. Sensitivity analyses largely confirmed the results of the main analysis.
Two of the researchers are employees of Biogen International, which supported the research. Several investigators received compensation or funding from various pharmaceutical companies.
STOCKHOLM – (CDP), according to an investigation presented at the annual congress of the European Committee for Treatment and Research in Multiple Sclerosis.
Using several confirmation points for Expanded Disability Status Scale (EDSS) progression (e.g., 12 months and 24 months), researchers detected a clear gradient of treatment effect. Identification of the most reliable outcome definitions will require further investigations, they said.
“The ultimate goal of MS treatment is the prevention of long-term disability accumulation,” said Giuseppe Lucisano, a biostatistician at the Center for Outcomes Research and Clinical Epidemiology in Pescara, Italy. “Continuous DMT exposure can impact long-term disability accumulation in MS, but it has not been definitively demonstrated yet.”
Registries and clinical databases provide the opportunity to collect longitudinal data for treated and untreated patients as a means of investigating questions such as this one, the researchers said. The Danish, Italian, and Swedish national MS registries, MSBase, and the Observatoire of MS (OFSEP) merged their data in the Big Multiple Sclerosis Data (BMSD) Network, which includes approximately 150,000 patients and more than 470,000 EDSS evaluations. The result is a large dataset suitable for long-term longitudinal studies.
Mr. Lucisano and colleagues sought to examine the long-term effect of DMTs on CDP and irreversible disability milestones (i.e., EDSS scores of 4 and 6) in relapsing-remitting MS. The researchers used marginal structural proportional models, a novel technique that enables them to correct modeling for confounders that vary with time in longitudinal observational studies. Such confounders include treatment switches, on-treatment relapses, and treatment gaps.
The investigators selected patients with 10 or more years’ follow-up and one or more EDSS score evaluations per year from the BMSD pooled cohort. Using marginal structural proportional models, the investigators evaluated cumulative hazards of 3-, 12- and 24-month CDP (i.e., CDP3, CDP12, CDP24) events in 6-month periods. They created stabilized inverse probability of treatment weights (IPTWs) at each 6-month period using survival models according to treatment status (i.e., treated versus untreated). Treatment status was assigned for each patient according to the percentage of time that he or she spent receiving DMT in each 6-month period. A patient who received treatment for 70% or more of the period studied was considered treated; patients who did not meet this threshold were considered untreated. The weights were calculated on the basis of sex, age, occurrence of relapse, EDSS score, and registry source. Finally, the researchers used Cox regression models estimating the effect of DMTs on the risk of reaching CDP3, CDP12, and CDP24, adjusted by the IPTWs, to compare cohorts that remained treated or untreated throughout follow-up.
The investigators identified a cohort of 15,602 patients with relapsing-remitting MS, and this group had 312,040 EDSS score evaluations. Approximately 28% of patients were male. Median age at disease onset was 28.3 years, and median disease duration was 18.7 years. Median follow-up duration was 13.8 years.
During follow-up, 43.3% of patients had CDP3, 27.7% had CDP12, and 14.4% had CDP24 events. In addition, 23.6% of patients reached an EDSS score of 4, and 11.2% reached an EDSS score of 6.
Cox models adjusted by IPTW demonstrated increasing positive evidence of the effect of cumulative treatment exposure, compared with cumulative untreated epochs, according to the length of confirmation time used for defining the CDP. The investigators did not observe an effect of treatment on the probability of reaching CDP3 (hazard ratio [HR], 1.02), but treatment had a protective effect on CDP12 (HR, 0.90) and CDP24 (HR, 0.65) endpoints. During treated epochs, the HR of EDSS 4 was 0.89, and the HR of EDSS 6 was 0.86. Sensitivity analyses largely confirmed the results of the main analysis.
Two of the researchers are employees of Biogen International, which supported the research. Several investigators received compensation or funding from various pharmaceutical companies.
STOCKHOLM – (CDP), according to an investigation presented at the annual congress of the European Committee for Treatment and Research in Multiple Sclerosis.
Using several confirmation points for Expanded Disability Status Scale (EDSS) progression (e.g., 12 months and 24 months), researchers detected a clear gradient of treatment effect. Identification of the most reliable outcome definitions will require further investigations, they said.
“The ultimate goal of MS treatment is the prevention of long-term disability accumulation,” said Giuseppe Lucisano, a biostatistician at the Center for Outcomes Research and Clinical Epidemiology in Pescara, Italy. “Continuous DMT exposure can impact long-term disability accumulation in MS, but it has not been definitively demonstrated yet.”
Registries and clinical databases provide the opportunity to collect longitudinal data for treated and untreated patients as a means of investigating questions such as this one, the researchers said. The Danish, Italian, and Swedish national MS registries, MSBase, and the Observatoire of MS (OFSEP) merged their data in the Big Multiple Sclerosis Data (BMSD) Network, which includes approximately 150,000 patients and more than 470,000 EDSS evaluations. The result is a large dataset suitable for long-term longitudinal studies.
Mr. Lucisano and colleagues sought to examine the long-term effect of DMTs on CDP and irreversible disability milestones (i.e., EDSS scores of 4 and 6) in relapsing-remitting MS. The researchers used marginal structural proportional models, a novel technique that enables them to correct modeling for confounders that vary with time in longitudinal observational studies. Such confounders include treatment switches, on-treatment relapses, and treatment gaps.
The investigators selected patients with 10 or more years’ follow-up and one or more EDSS score evaluations per year from the BMSD pooled cohort. Using marginal structural proportional models, the investigators evaluated cumulative hazards of 3-, 12- and 24-month CDP (i.e., CDP3, CDP12, CDP24) events in 6-month periods. They created stabilized inverse probability of treatment weights (IPTWs) at each 6-month period using survival models according to treatment status (i.e., treated versus untreated). Treatment status was assigned for each patient according to the percentage of time that he or she spent receiving DMT in each 6-month period. A patient who received treatment for 70% or more of the period studied was considered treated; patients who did not meet this threshold were considered untreated. The weights were calculated on the basis of sex, age, occurrence of relapse, EDSS score, and registry source. Finally, the researchers used Cox regression models estimating the effect of DMTs on the risk of reaching CDP3, CDP12, and CDP24, adjusted by the IPTWs, to compare cohorts that remained treated or untreated throughout follow-up.
The investigators identified a cohort of 15,602 patients with relapsing-remitting MS, and this group had 312,040 EDSS score evaluations. Approximately 28% of patients were male. Median age at disease onset was 28.3 years, and median disease duration was 18.7 years. Median follow-up duration was 13.8 years.
During follow-up, 43.3% of patients had CDP3, 27.7% had CDP12, and 14.4% had CDP24 events. In addition, 23.6% of patients reached an EDSS score of 4, and 11.2% reached an EDSS score of 6.
Cox models adjusted by IPTW demonstrated increasing positive evidence of the effect of cumulative treatment exposure, compared with cumulative untreated epochs, according to the length of confirmation time used for defining the CDP. The investigators did not observe an effect of treatment on the probability of reaching CDP3 (hazard ratio [HR], 1.02), but treatment had a protective effect on CDP12 (HR, 0.90) and CDP24 (HR, 0.65) endpoints. During treated epochs, the HR of EDSS 4 was 0.89, and the HR of EDSS 6 was 0.86. Sensitivity analyses largely confirmed the results of the main analysis.
Two of the researchers are employees of Biogen International, which supported the research. Several investigators received compensation or funding from various pharmaceutical companies.
REPORTING FROM ECTRIMS 2019
Neurologists need not discourage breastfeeding in women with MS
STOCKHOLM – Most neurologists are overly conservative when it comes to advising women with multiple sclerosis (MS) about breastfeeding, discouraging this broadly beneficial practice in favor of early resumption of treatment post pregnancy, Kerstin Hellwig, MD, said at the annual congress of the European Committee for Treatment and Research in Multiple Sclerosis.
“We should change our behavior, and I predict we will change it so that more women are breastfeeding while under MS medication within the next couple years. ,” said Dr. Hellwig, senior consultant and MS specialist in the department of neurology at St. Josef Hospital/Ruhr University in Bochum, Germany.
She was a coauthor of a groundbreaking 2012 meta-analysis that concluded that breastfeeding by MS patients is not harmful (J Neurol. 2012 Oct;259[10]:2246-8), a finding since confirmed in multiple additional studies.
“Women with MS who want to breastfeed should be supported in doing so,” Dr. Hellwig said.
In this regard, many neurologists are out of step with their colleagues in rheumatology and gastroenterology, who commonly endorse breastfeeding by their patients while on monoclonal antibodies for other autoimmune diseases, according to Dr. Hellwig.
It is important to recognize that most women of reproductive age with MS have milder forms of the disease, she said. They can safely breastfeed without being on any MS medications at all for the duration.
For women who want to breastfeed and have more-active disease where early treatment resumption is warranted, the key is to select a breastfeeding-compatible medication. The main determinant of whether a drug will enter the mother’s breast milk is the size of the drug molecule, with large molecules being unlikely to make their way into breast milk in anything approaching clinically meaningful amounts. The injectable first-line disease-modifying drugs are good options: For example, interferon-beta is a very large molecule which has been detected in breast milk at 0.0006% of the relative infant dose. That’s reassuring, Dr. Hellwig said, since anything less than a relative infant dose of 10% is generally considered to be safe for a baby. And while glatiramer acetate, another injectable, has not been tested, it is metabolized so rapidly that it is unlikely to be detectable in breast milk, according to Dr. Hellwig.
Monoclonal antibodies are also compatible with breastfeeding. Rituximab has been detected in breast milk at 1/240th of the maternal serum level, and natalizumab at less than 1/200th. These are large molecules with a low likelihood of infant absorption, since they are probably destroyed in the child’s gastrointestinal tract. Ocrelizumab has not been studied in breast milk, but it is an IgG1 monoclonal antibody, as is rituximab, and so should likewise pose “exceedingly low risk,” Dr. Hellwig said.
At last year’s ECTRIMS conference, she presented reassuring 1-year follow-up data on a cohort of infants breastfed by mothers with MS while on interferon-beta. “We do not see any growth disturbances, any severe infections, hospitalizations, excess antibiotic use, or postponed reaching of developmental milestones in babies being breastfed under the injectables,” she said.
Dr. Hellwig has served on scientific advisory board for Bayer, Biogen, Genzyme Sanofi, Teva, Roche, Novartis, and Merck. She has received speaker honoraria and research support from Bayer, Biogen, Merck, Novartis, SanofiGenzyme, and Teva, and has received support for congress participation from Bayer, Biogen, Genzyme, Teva, Roche, and Merck.
STOCKHOLM – Most neurologists are overly conservative when it comes to advising women with multiple sclerosis (MS) about breastfeeding, discouraging this broadly beneficial practice in favor of early resumption of treatment post pregnancy, Kerstin Hellwig, MD, said at the annual congress of the European Committee for Treatment and Research in Multiple Sclerosis.
“We should change our behavior, and I predict we will change it so that more women are breastfeeding while under MS medication within the next couple years. ,” said Dr. Hellwig, senior consultant and MS specialist in the department of neurology at St. Josef Hospital/Ruhr University in Bochum, Germany.
She was a coauthor of a groundbreaking 2012 meta-analysis that concluded that breastfeeding by MS patients is not harmful (J Neurol. 2012 Oct;259[10]:2246-8), a finding since confirmed in multiple additional studies.
“Women with MS who want to breastfeed should be supported in doing so,” Dr. Hellwig said.
In this regard, many neurologists are out of step with their colleagues in rheumatology and gastroenterology, who commonly endorse breastfeeding by their patients while on monoclonal antibodies for other autoimmune diseases, according to Dr. Hellwig.
It is important to recognize that most women of reproductive age with MS have milder forms of the disease, she said. They can safely breastfeed without being on any MS medications at all for the duration.
For women who want to breastfeed and have more-active disease where early treatment resumption is warranted, the key is to select a breastfeeding-compatible medication. The main determinant of whether a drug will enter the mother’s breast milk is the size of the drug molecule, with large molecules being unlikely to make their way into breast milk in anything approaching clinically meaningful amounts. The injectable first-line disease-modifying drugs are good options: For example, interferon-beta is a very large molecule which has been detected in breast milk at 0.0006% of the relative infant dose. That’s reassuring, Dr. Hellwig said, since anything less than a relative infant dose of 10% is generally considered to be safe for a baby. And while glatiramer acetate, another injectable, has not been tested, it is metabolized so rapidly that it is unlikely to be detectable in breast milk, according to Dr. Hellwig.
Monoclonal antibodies are also compatible with breastfeeding. Rituximab has been detected in breast milk at 1/240th of the maternal serum level, and natalizumab at less than 1/200th. These are large molecules with a low likelihood of infant absorption, since they are probably destroyed in the child’s gastrointestinal tract. Ocrelizumab has not been studied in breast milk, but it is an IgG1 monoclonal antibody, as is rituximab, and so should likewise pose “exceedingly low risk,” Dr. Hellwig said.
At last year’s ECTRIMS conference, she presented reassuring 1-year follow-up data on a cohort of infants breastfed by mothers with MS while on interferon-beta. “We do not see any growth disturbances, any severe infections, hospitalizations, excess antibiotic use, or postponed reaching of developmental milestones in babies being breastfed under the injectables,” she said.
Dr. Hellwig has served on scientific advisory board for Bayer, Biogen, Genzyme Sanofi, Teva, Roche, Novartis, and Merck. She has received speaker honoraria and research support from Bayer, Biogen, Merck, Novartis, SanofiGenzyme, and Teva, and has received support for congress participation from Bayer, Biogen, Genzyme, Teva, Roche, and Merck.
STOCKHOLM – Most neurologists are overly conservative when it comes to advising women with multiple sclerosis (MS) about breastfeeding, discouraging this broadly beneficial practice in favor of early resumption of treatment post pregnancy, Kerstin Hellwig, MD, said at the annual congress of the European Committee for Treatment and Research in Multiple Sclerosis.
“We should change our behavior, and I predict we will change it so that more women are breastfeeding while under MS medication within the next couple years. ,” said Dr. Hellwig, senior consultant and MS specialist in the department of neurology at St. Josef Hospital/Ruhr University in Bochum, Germany.
She was a coauthor of a groundbreaking 2012 meta-analysis that concluded that breastfeeding by MS patients is not harmful (J Neurol. 2012 Oct;259[10]:2246-8), a finding since confirmed in multiple additional studies.
“Women with MS who want to breastfeed should be supported in doing so,” Dr. Hellwig said.
In this regard, many neurologists are out of step with their colleagues in rheumatology and gastroenterology, who commonly endorse breastfeeding by their patients while on monoclonal antibodies for other autoimmune diseases, according to Dr. Hellwig.
It is important to recognize that most women of reproductive age with MS have milder forms of the disease, she said. They can safely breastfeed without being on any MS medications at all for the duration.
For women who want to breastfeed and have more-active disease where early treatment resumption is warranted, the key is to select a breastfeeding-compatible medication. The main determinant of whether a drug will enter the mother’s breast milk is the size of the drug molecule, with large molecules being unlikely to make their way into breast milk in anything approaching clinically meaningful amounts. The injectable first-line disease-modifying drugs are good options: For example, interferon-beta is a very large molecule which has been detected in breast milk at 0.0006% of the relative infant dose. That’s reassuring, Dr. Hellwig said, since anything less than a relative infant dose of 10% is generally considered to be safe for a baby. And while glatiramer acetate, another injectable, has not been tested, it is metabolized so rapidly that it is unlikely to be detectable in breast milk, according to Dr. Hellwig.
Monoclonal antibodies are also compatible with breastfeeding. Rituximab has been detected in breast milk at 1/240th of the maternal serum level, and natalizumab at less than 1/200th. These are large molecules with a low likelihood of infant absorption, since they are probably destroyed in the child’s gastrointestinal tract. Ocrelizumab has not been studied in breast milk, but it is an IgG1 monoclonal antibody, as is rituximab, and so should likewise pose “exceedingly low risk,” Dr. Hellwig said.
At last year’s ECTRIMS conference, she presented reassuring 1-year follow-up data on a cohort of infants breastfed by mothers with MS while on interferon-beta. “We do not see any growth disturbances, any severe infections, hospitalizations, excess antibiotic use, or postponed reaching of developmental milestones in babies being breastfed under the injectables,” she said.
Dr. Hellwig has served on scientific advisory board for Bayer, Biogen, Genzyme Sanofi, Teva, Roche, Novartis, and Merck. She has received speaker honoraria and research support from Bayer, Biogen, Merck, Novartis, SanofiGenzyme, and Teva, and has received support for congress participation from Bayer, Biogen, Genzyme, Teva, Roche, and Merck.
EXPERT ANALYSIS FROM ECTRIMS 2019