DALLAS—Patients with multiple sclerosis (MS) who have a higher BMI and weight in early adulthood have a younger age of MS symptom onset and diagnosis, according to research presented at the 2014 Cooperative Meeting of the CMSC and ACTRIMS.
Katelyn S. Kavak, from the Jacobs MS Center in Buffalo, New York, and colleagues based their findings on a study of 237 women who were registered with the New York State MS Consortium, had completed a questionnaire about reproductive events, and were treated at the investigators’ MS care center. All study participants were asked to recall their weight at the time of their first menstruation and at age 25.
The researchers calculated BMI for age 25 but not for the time of first menstruation, because “height measures in adolescence could not reliably be deduced.” The investigators used regression analysis to examine the association between weight or BMI as a continuous measure and age at MS onset and diagnosis. In addition, the study authors compared people who were overweight with those who were not overweight, defining those who were overweight as having a BMI greater than or equal to 25 and those who were not overweight as having a BMI less than 25.
“Weight of subjects at their first menstruation was significantly related to younger age at [MS symptom] onset and diagnosis,” reported the researchers. “These results were also found at age 25 for onset and diagnosis. Subjects with higher BMI at age 25 were younger at onset and diagnosis.” Further analysis that compared overweight and nonoverweight persons found that those who were overweight at age 25 had a “significantly earlier” age at MS symptom onset and diagnosis.
“Future research should investigate whether there is a causal link between body weight and MS, as there may be underlying genetic or environmental factors, such as vitamin D deficiency, that could influence the results,” the researchers concluded.
—Colby Stong
A Personalized Management Plan of Fingolimod Titration May Benefit Some Patients With MS
Long-term data demonstrating the success of interferon titration suggest that a similar strategy could be effective for a select group of patients who have difficulty tolerating the initial recommended 0.5-mg daily fingolimod dose. Data suggest that there may be a role for fingolimod 0.25 mg/day; however, the optimal recommended therapeutic dose of 0.5 mg/day is achievable for many patients if side effects and titration are managed efficiently and effectively.
A major Australian tertiary teaching hospital with a large multiple sclerosis (MS) clinic anticipated that patients starting on fingolimod and experiencing poor drug tolerability would request, or simply decide on their own, to cease their medication. Historical experience with interferon prompted discussions with the neurologist and MS nursing staff. Through consultation in relation to dosing alternatives, an opportunity to explore individualized oral drug titration was identified. Select patients whose quality of life was being disrupted by unwanted side effects were offered a titration and monitoring opportunity. The goal of the “go slow” approach was to achieve the full recommended daily dose regimen and establish confidence with a nonexistent or minimal acceptable side effect profile.
Susanne Baker and Meena Sharma from the MS Clinic at Liverpool Hospital in Sydney, Australia, in collaboration with neurologists, endeavored to manage side effects and titrate the fingolimod dose according to side effects experienced. Patients who chose to withdraw from fingolimod treatment were given the option of a personalized management plan. No clinical assessment tool was used to grade the severity of the adverse events, and all supportive care was given based on the patients’ self-report of discomfort. The program offered regular monitoring and side effect management for lymphopenia, gastrointestinal disturbance, headache, and a feeling of being generally unwell. Ongoing consultation with the neurologist by the MS nursing staff was maintained along with fingolimod dose adjustments. Supportive medication included, but was not limited to, paracetamol, ibuprofen, ranitidine, metoclopramide, and loperamide.
In total, 209 patients were treated with fingolimod at the MS clinic at Liverpool Hospital, and 51 (24.4%) significant adverse events (eg, lymphopenia, herpes zoster, malignancy, headache, ophthalmologic symptoms, gastrointestinal disturbance, and a feeling of being generally unwell) were reported. From this patient group, 24 (47%) were offered a side effect management and drug titration plan. Sixteen patients (66.7%) chose to participate in the proposed plan. A total of 10 participants were able to achieve the full dose and remain on treatment, two (12.5%) patients discontinued treatment due to poor tolerance, and four (25%) patients remained on drug titration. No relapses were observed or reported during the titration period.