a virtual reality view selecting disease-modifying therapy ... · 26/05/2020 · the reviewer of...

This activity is supported by educational grants from Biogen, Genentech, a member of the Roche Group, and Sanofi Genzyme. T his activity is provided by Med Learning Group. T his activity is co-provided by Ultimate Medical Academy /Complete Conference Management (CCM).

TUESDAY, MAY 26, 2020

A VIRTUAL REALITY VIEW Selecting Disease-Modifying Therapy for Multiple Sclerosis: Tools to Achieve and Maintain Control of a Dynamic Disease

Selecting Disease‐Modifying Therapy for Multiple Sclerosis: Tools to Achieve and Maintain Control of a Dynamic Disease

FACULTY Patricia K. Coyle, MD, FAAN, FANA

Professor and Interim Chair Director, MS Comprehensive Care Center Stony Brook University Medical Center

Stony Brook, New York

PROGRAM OVERVIEW This activity will cover the treatment and management of patients with multiple sclerosis (MS).

TARGET AUDIENCE This activity is designed to meet the needs of neurologists, nurses, nurse practitioners, and other healthcare professionals treating patients with MS.

Learning Objectives

Review MS classification and differences in presentation to encourage earlier diagnosis and promptinitiation of treatment

Improve clinician/patient communication and patient engagement to better pursue favorableoutcomes

Establish ways in which to overcome barriers to adherence in MS treatment

Evaluate the safety and efficacy of current and emerging agents used for MS

ACCREDITATION STATEMENT Med Learning Group is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. This CME activity was planned and produced in accordance with the ACCME Essentials.

CREDIT DESIGNATION STATEMENT Med Learning Group designates this live activity for a maximum of 1.25 AMA Category 1 CreditsTM. Physicians should claim only the credit commensurate with the extent of their participation in the live activity.

NURSING CREDIT INFORMATION Purpose: This program would be beneficial for nurses involved in the long‐term treatment and management of patients with NMOSD. CNE Credits: 1.25 ANCC Contact Hour(s).

CNE ACCREDITATION STATEMENT Ultimate Medical Academy/CCM is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation. Awarded 1.25 contact hour of continuing nursing education of RNs and APNs.

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members participating in a MLG‐sponsored activity are required to disclose any relevant financial interest or other relationship with the manufacturers of any commercial products and/or providers of commercial services that are discussed in an educational activity. DISCLOSURE OF CONFLICTS OF INTEREST Patricia Coyle, MD, FAAN, FANA has received consultant fees from Accordant, Alexion, Bayer, Biogen Idec, Celgene, Genentech/Roche, Genzyme/Sanofi, GlaxoSmithKline, Mylar, Novartis, Serono, and TG Therapeutics. Dr. Coyle has received research funding from Actelion, Alkermes, Corrona LLD, Genentech/Roche, MedDay, NINDS, and Novartis and PCORI. CME Content Review The content of this activity was independently peer‐reviewed. The reviewer of this activity has nothing to disclose. CNE Content Review The content of this activity was peer‐reviewed by a nurse reviewer. The reviewer of this activity has nothing to disclose. The staff, planners and managers reported the following financial relationships or relationships to products or devices they or their spouse/life partner have with commercial interests related to the content of this CME/CE activity: Matthew Frese, General Manager of Med Learning Group has nothing to disclose. Christina Gallo, SVP, Educational Development of Med Learning Group has nothing to disclose. Ashley Whitehurst, Program Manager of Med Learning Group has nothing to disclose. Chris Drury, Medical Director of Med Learning Group has nothing to disclose. Lauren Welch, MA, VP of Accreditation and Outcomes of Med Learning Group has nothing to disclose. Russie Allen, Accreditation and Outcomes Coordinator of Med Learning Group has nothing to disclose.

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This activity is provided by Med Learning Group.

This activity is co‐provided by Ultimate Medical Academy/Complete Conference Management (CCM).

This activity is supported by educational grants from Biogen, Genentech, a member of the Roche Group, and Sanofi Genzyme.

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AGENDA

Part I: MS Overview and Diagnosis

Epidemiology and pathophysiology MS phenotypes and diagnostic criteria Etiology/triggers/environmental factors Disease course/prognosis

Part II: Initiating Treatment with Shared Decision‐Making

Initial treatment considerations Improving engagement in patient care Encouraging medication adherence Shared decision‐making Case study

Part III: Current and Novel Treatment Options

MS treatment options o Established conventional treatments (interferon, glatiramer acetate) o Newer agents (monoclonal antibodies, oral agents, etc.) o Ongoing clinical trials

Treatment guidelines and safety considerations Emerging treatments/classes: CD20/CD25, S1P‐R modulators, vaccine‐based therapies,

remyelinating agents, stem cells, etc. Results of recent and ongoing clinical trials of agents in late‐stage development

Part IV: Questions/Answers

May 26, 2020 6:45 pm ET

1

Selecting Disease‐Modifying Therapy for Multiple Sclerosis:

Tools to Achieve and Maintain Control of a Dynamic Disease

Patricia K. Coyle, MD

Professor and Interim Chair

Director, MS Comprehensive Care Center

Stony Brook University Medical Center

Stony Brook, NY

Disclosures

• Dr. Coyle has received consultant fees from Accordant, Actelion, Alexion, Bayer, Biogen, Celgene, Genentech/Roche, Genzyme/Sanofi, Novartis, Serono, and TG Therapeutics and has contracted research from Actelion, Genentech/Roche, MedDay, the National Institute of Neurological Disorders and Stroke (NINDS), and Novartis.

• During the course of this lecture, Dr. Coyle may mention the use of medications for both FDA‐approved and non‐approved indications.

• This activity is supported by an educational grant from Biogen, Genentech, a member of the Roche Group, and Sanofi Genzyme.

2

Learning Objectives

• Review MS classification and differences in presentation to encourage earlier diagnosis and prompt initiation of treatment

• Improve clinician/patient communication and patient engagement to better pursue favorable outcomes

• Establish ways in which to overcome barriers to adherence in MS treatment

• Evaluate the safety and efficacy of current and emerging agents used for MS

MS: Definition and Demographics

• MS is the major acquired CNS disorder of young adults

• 2017 estimate: 913,925 MS individuals in the US; >2.5 million affected worldwide

– Autopsy studies suggest 25% of MS may be silent

– MS varies in frequency worldwide, with a latitudinal impact

• 90% of cases present in people aged 15 to 50 years

– Pediatric MS accounts for 2%–5% of cases; <1% occurs before age 10

– Less than 10% over age 50 years (late onset); <1% ≥60 years (very late onset)

Ma VY, et al. Arch Phys Med Rehabil. 2014;95:986‐995;.e1. National Multiple Sclerosis Society. MS prevalence FAQs (www.nationalmssociety.org/About‐the‐Society/MS‐Prevalence‐FAQ). Accessed 2/11/2020. Wallin MT, et al. Neurology. 2019;92:e1029‐e1040.

MS = multiple sclerosis; CNS = central nervous system.

3

MS: Definition and Demographics(continued)

• Highly variable course (silent, “benign,” malignant)

• Female‐to‐male ratio is 3:1. MS is increasing in women; study in Denmark noted 114% in women, especially ages 50–64, vs 30% in men

• MS predominantly affects Caucasians (>90%) but now is increasing in other populations

• Lifespan is shortened by about 6–12 years due to complications in disabled MS, brainstem involvement, and suicide.

National Multiple Sclerosis Society (www.nationalmssociety.org/About‐the‐Society/MS‐Prevalence‐FAQs). Accessed 2/11/2020. Koch‐Henriksen N, et al. Neurology. 2018;90:e1954‐e1963.

Geographic Distribution and Inheritance of MS in Migrants

Adapted from McAlpine D, Lumadan CE, Acheson ED. Multiple Sclerosis: a Reappraisal. Livingstone Ltd., London, 1967.

4

Pathophysiology/Disease Mechanisms

MS Neuropathology

• Focus is on inflammation (focal and diffuse), demyelination, and neurodegeneration (axonal/neuronal/synapse injury)

• Macroscopic (plaques)

– Form around venules, close to CSF

– Edema, inflammation, demyelination, axonal injury, neuronal/oligo loss, astrocytosis, and remyelination (70%–80%)

Dal‐Bianco A, et al. Eur Radiol. 2015;25:2913‐2920.

CSF = cerebrospinal fluid.

5

MS Neuropathology(continued)

• Microscopic changes

– Ion channel changes

– Synapse loss

– Axoglial unit injury

• Myelocortical MS (swollen axons)

– 12% of MS

• Circuit/network disruption

• Ongoing injury occurs in untreated patients, even when they appear stable.

Dal‐Bianco A, et al. Eur Radiol. 2015;25:2913‐2920. Trapp BD, et al. Lancet Neurol. 2018; 17:870‐884.

MS Pathophysiology

• Outside‐in hypothesis

– Relapsing MS

– Focal inflammation

– Most DMTs succeed, based on systemic impact

• Inside‐out hypothesis

– Progressive MS

– Neurodegeneration

– CNS signal triggers focal inflammation

– Role for glia: altered oligo heterogeneity, regional microglial activation and heterogeneity, astrocyte metabolism implicated in progressive MS damage

van der Poel M, et al. Nat Commun. 2019;10:1139.

DMT = disease‐modifying therapy.

6

Disease Course/Prognosis

MS Endophenotype

• At‐risk population

• Radiologically isolated syndrome (RIS)

• Prodromal MS

• Clinically isolated syndrome (CIS)/relapsing or primary progressive MS (PPMS)

Lublin FD, et al. Neurology. 2014;83:278‐286.

7

Prodromal MS

• Matched cohort study from linked health administrative/clinical databases from 4 Canadian provinces1,2

– For 14,428 MS patients vs 72,059 matched controls, annual healthcare use (ie, hospital admissions, physician claims, prescriptions) went up steadily from years 5 to 1 prior to CIS

– More nervous, sensory, musculoskeletal, and genitourinary issues and psychiatry/urology encounters

• UK nested case‐control study of 10,204 patients with MS vs 39,448 controls3

– Primary care use in prior 10 years showed gastric, urinary, anorectal, anxiety/depression; headache/pain; and fatigue/insomnia

– risk of MS with complaints

1. Wijnands JMA, et al. Lancet Neurol. 2017;16:445‐451. 2. Wijnands JM, et al. Mult Scler. 2019;25:1092‐1101. 3. Disanto G, et al. Ann Neurol. 2018;83:1162‐1173.

MS Prodrome

• N=4,862 MS vs N=22,649 UK controls: in 5 years pre‐MS vs controls, use of specific drugs (anti‐vertigo, anti‐epileptic, glucocorticoids, urinary anti‐spasmodics, muscle relaxants)1

• N=8,669 MS and N=40,867 Canadian controls: hospitalizations related to urinary system/spinal cord, and urinary anti‐spasmodics/anti‐vertigo prescriptions, carried 2‐3x risk of MS2

• N=60 MS, N=60 controls; DOD serum repository; serum NfL protein levels elevated in pre‐MS vs controls a median of 6 yrs (4‐10 yrs) before onset of MS3

– Levels closer to MS presentation

1. Zhao Y, et al. Neuroepidemiology. 2020; Jan 15:1‐8. 2. Högg T, et al. Mult Scler Relat Disord. 2018;25:232‐240. 3. Bjornevik K, et al. JAMA Neurol. 2020;77:58‐64.

NfL = neurofilament light chain

8

MS Prodrome

• N=8 non‐declared MS monozygotic twins of MS patients

– All showed either MRI lesions c/w subclinical neuroinflammation (N=6), and/or +CSF OCBs (N=4)

– Only N=2 met RIS criteria

– Single cell RNA sequencing of CSF cells showed clonal activation and expansion of CD8+ T cells (activated tissue, resident memory T cells); small proportion of clonally expanded CD4+ T cells; expanded plasmablasts only with +OCBs

• Conclusion: very early activation of adaptive immunity in prodromal MS (esp CD8+ T cells)

Beltrán E et al. J Clin Invest. 2019;129:4758‐4768.

MRI = magnetic resonance imaging; RNA = ribonucleic acid; CD = cluster of differentiation; OCB = oligoclonal bands.

MS Prodrome

• Retrospective analysis of 385 patients with MS and reported bowel symptoms at 2 tertiary centers (MGH and BWH)

• 122 (31.6%) reported bowel symptoms prior to CIS: 50% with constipation and 29.5% with diarrhea

– Average time between first bowel symptom and CIS was 3.7 3.4 years

– Pre‐CIS fatigue (P<.001) and pre‐CIS sensory disturbances (P<.05) were associated with bowel symptoms prior to a CIS event

Almeida MN et al. Neurogastroenterol Motil. 2019;31:e13592.

MGH = Massachusetts General Hospital; BWH = Brigham and Women’s Hospital.

9

MS Phenotypes


Clinical Patterns of MS

Radiologically isolated syndrome (RIS) (not officially recognized)

Prodromal MS (not officially recognized)

Clinically isolated syndrome (CIS)• Categorized as high/low risk for MS based on brain MRI

• Now recognized by FDA as relapsing form of MS

Relapsing-remitting MS (RRMS)

Primary progressive MS (PPMS)

Secondary progressive MS (SPMS)• Active SPMS now recognized by FDA as relapsing form of MS

FDA = US Food and Drug Administration.

MS Disease Activity

• Two modifiers specified

• Considered over a defined timeframe (eg, 1 year)

• Active or not active

– Involves clinical and MRI measures

– Applies to all phenotypes

– Determined by clinical relapse or by new/enlarging T2 or contrast + MRI lesion


10

Audience Response Question: MS Types

Which of the following types of MS is NOT associated with relapses?

A. Primary progressive, active

B. Primary progressive, not active

C. Secondary progressive

D. Relapsing‐remitting

MS Disease Activity

Progressing or not progressing

• Applies to progressive phenotypes

• Determined by presence/absence of gradual clinical worsening, independent of relapses

• No MRI measure


11

MS Prognostic Profile

Good Poor

Race Caucasian Black

Age at onset younger (35 years) older (35 years)

Sex female male

Smoker no yes

Vascular risk factors/comorbidities absent present

Cognitive dysfunction absent present

Phenotype relapsing progressive

First attackoptic neuritis,

sensory, unifocalmotor, cerebellar,

sphincter, multifocal

Recovery complete incomplete

Attack rate low high (2 in 1 year)

Prognostic Factors

Good Poor

Disability at 5 years no yes

MRI: lesion location cerebral posterior fossa; spinal cord; cortical

Number low high (≥9)

Enhancement 0–2 >2

Chronic T1 hypointense lesions absent present

Early discernable atrophy no yes

CSF OCBs (IgG; IgM) absent positive

OCT RNFL thicker thinner

NFL levels not elevated elevated

Multimodal EP abnormalities low score high score

IgG = immunoglobulin G; IgM = immunoglobulin M; OCT = optical coherence tomography; RNFL = retinal nerve fiber layer; NFL = nerve fiber layer; EP = evoked potential.

12

Diagnostic Guidelines

2017 Revised McDonald Diagnostic Criteria

• The 2017 revisions amplify and clarify the 2010 criteria to simplify and facilitate early diagnosis and preserve specificity to reduce misdiagnosis

• They re‐emphasize that criteria were developed for typical CIS and are not intended for use with non‐specific symptoms

• Clarify MRI lesion size (≥3 mm); periventricular lesions must abut ventricles, juxtacortical lesions abut cortex

• The criteria recommend caution in attribution of historical events in the absence of corroborating objective evidence

CIS = clinically isolated syndrome.

Polman CH, et al. Ann Neurol. 2011;69:292‐302; Thompson AJ, et al. Lancet Neurol. 2018;17:162‐173.

13

2017 Revised McDonald Diagnostic Criteria(continued)

• Criteria continue to require exclusion of better alternate explanations for presentation

• Although guidelines still allow diagnosis of MS on purely clinical grounds, MRI is recommended in all patients considered for MS diagnosis, and caution is urged in diagnosing MS in the absence of typical lesions on MRI

• In addition to diagnosis, determination of a provisional disease phenotype course is recommended

Polman CH, et al. Ann Neurol. 2011;69:292‐302. Thompson AJ, et al. Lancet Neurol. 2018;17:162‐173.

2017 Revised McDonald Diagnostic CriteriaValue of CSF

• The value of CSF is re‐emphasized in the 2017 revisions

• Demonstration of unique CSF oligoclonal bands is the most reliable test of intrathecal antibody production, and the importance of using appropriate standardized technology is noted

Thompson AJ, et al. Lancet Neurol. 2018;17:162‐173.

CSF = cerebrospinal fluid.

14

2017 Revised McDonald Diagnostic CriteriaRecommendations for CSF

• Threshold for CSF should be low

• CSF is particularly recommended when:

– Clinical and MRI evidence is insufficient or atypical

– Presentation is other than typical CIS, including a progressive course

– Atypical features

– Populations in which MS is less common (eg, non‐Caucasians, older age groups)

Thompson AJ, et al. Lancet Neurol. 2018;17:162‐173.

2017 Revised McDonald Diagnostic CriteriaDIS and DIT

Dissemination in space (DIS)

• Lesions in two characteristic locations

– Periventricular

– Juxtacortical/cortical

– Infratentorial

– Spinal cord

• Symptomatic and asymptomatic lesions count

Dissemination in time (DIT)

• Simultaneous enhancing and non‐enhancing lesions

• New lesions on subsequent MRI at any time point

• In patient with typical CIS meeting DIS criteria and no better explanation, CSF oligoclonal bands can substitute for DIT.


15

2017 Revised McDonald Diagnostic Criteria Progressive from MS Onset


Progressive from Onset of MS

• ≥1-year progression of neurologic impairment (prospective, retrospective) plus

• 2 of 3 criteria

– ≥1 T2 lesion in characteristic brain area (periventricular, juxtacortical/cortical, infratentorial)

– ≥2 T2 cord lesions

– CSF oligoclonal bands

2017 Revised McDonald Diagnostic CriteriaMisdiagnosis

• Misdiagnosis remains a clinical issue (at least 5%–10%; up to 20% reported)

• Several factors identified

– MS heterogeneity

– No single pathognomonic clinical feature/diagnostic biomarker

– Nonspecific MRI findings; MRI lesions seen in other diseases

– Increasing focus on early diagnosis

Thompson AJ, et al. Lancet Neurol. 2018;17:162‐173. Toledano M, et al. Curr Neurol Neurosci Rep. 2015;15:57. Kaisey M, et al. Mult Scler Relat Disord. 2019;30:51‐56.

16

Diagnostic Evaluation

• Clinical findings supported by laboratory data

• Blood work (to rule out confounding diagnoses)

• MRI

– Brain MRI ± contrast

– Cervical/thoracic MRI (include conus)

• CSF

– Oligoclonal bands

– IgG index/intrathecal IgG antibody production

– Cell count, protein

– Myelin basic protein is nonspecific injury marker

Thompson AJ, et al. Lancet Neurol. 2018;17:162‐173. Toledano M, et al. Curr Neurol Neurosci Rep. 2015;15:57.

Problem of MS Misdiagnosis Study of 110 Misdiagnosed Patients

Contributors to MS misdiagnosis

• Inappropriate application of MS diagnostic criteria to atypical symptoms

• Inappropriate application of diagnostic criteria to historical episode without corroborating objective evidence

• Overreliance on MRI abnormalities in patients with nonspecific symptoms

• Erroneous determination of juxtacortical or periventricular lesion location

• Erroneous determination of DIT due to variability of slice orientation on serial images

Most common alternate diagnoses

• Migraine with MRI abnormalities

• Fibromyalgia

• Nonspecific/non‐localizing symptoms with MRI abnormalities

• Psychogenic or conversion disorders

• NMOSD

Solomon AJ, et al. Neurology. 2016;87:1393‐1399.

Authors note that strict adherence to clinical and radiographic MS diagnostic criteria may have

prevented misdiagnosis in many patients and that atypical symptoms for a demyelinating attack contributed to misdiagnosis in almost 2 out of 3

patients.

NMOSD = neuromyelitis optica spectrum disorder.

17

Initiating Treatment WithShared Decision‐Making

Initiating Treatment: Real‐World Considerations

• Disease factors

– Frequency and severity of relapses

– Duration since MS onset

– Lesion burden on MRI

– Lesion location

– Residual deficits/EDSS

• Access factors

– Formulary restrictions

– Out‐of‐pocket costs

• Drug factors

– Potency/safety preference

– Risk

– Monitoring requirements

– Route of administration

• Patient factors

– Age

– Future pregnancy

– Comorbidities

– Impairment impacting monitoring or adherence

– Ethnicity

– Risk tolerance

Kalincik T, et al. Brain. 2017;140:2426‐2443. Wingerchuk DM, Weinshenker BG. BMJ. 2016;354:i3518. Rush CA, et al. Nat Rev Neurol .2015;11:379‐389.

EDSS = Expanded Disability Status Scale.

18

Improving Engagement in Patient Care

Elicit individual risk/benefit preferences

• Relative values of preventing future disability vs fear of side effects

• Present data in understandable terms

• Recognize potential for conflicting information from alternate sources

• Patient tolerance for risk may be greater than that of their physician(s)

• Establish a non‐judgmental trusting relationship, even if the patient’s treatment decision may conflict with your recommendation

Strategies to optimize DMT adherence

• Educate patients

– Disease course

– Treatment rationale and accurate expectations

– Potential adverse effects and management

• Empathic attention

– Adjustment to coping with a chronic disease

– Recognizing treatment impacts on lifestyle

– Anticipate doubts when breakthrough occurs or when long‐term stability leads to questions regarding need for DMT

– Reinforce treatment adherence and evidence of benefit

Wilson L, et al. J Neurol Sci. 2014;344:80‐87. Clanet MC, et al. Mult Scler. 2014;20:1306‐1311. Giovannoni G, Rhoades RW. Curr Opin Neurol. 2012;25(suppl):S20‐S27. Johnson FR, et al. J Neurol. 2009;256:554‐562. Cohen BA. Int J MS Care. 2006;8(suppl 1):32‐37.

Four Models of Clinician‐Patient Relationship

Berger JR, Markowitz C. JAMA Neurol. 2018;75:1461‐1462.

1. Paternalistic• Making the decision for the patient with limited collaboration (eg, choosing a DMT without providing alternatives or explanation)

2. Informative• Fact‐based information on disease treatment, rather than patient‐centered care

• Passive, lack of clarification

3. Interpretive• Help the patient select treatment by listing all options and determining what the patient prefers

• Problem: patient may have incomplete information/understanding

4. Deliberative• Engage in discussion on what health values the patient could/should pursue

• Encourage “informed exercise of choice”

Preferred model

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MS: Opportunities for Patient‐Led Care

“Multiple sclerosis is a preference‐sensitive condition and provides the opportunity to implement decision aids at various decision points in the disease process.”

“In a shared decision‐makingmodel…the physician elicits the patient’s values and preferences about their care, has an evidence‐based discussion of treatment options,

and then the patient and physician arrive at a treatment decision together.”

Colligan E, et al. Mult Scler. 2017;23:185‐190.

Shared Decision Making (SDM)

When patients engage in shared decision making they...

• Learn about their health and understand their health conditions

• Recognize that a decision needs to be made and are informed about the options

• Understand the pros and cons of different options

• Have the information and tools needed to evaluate their options

• Are better prepared to talk with their provider

• Collaborate with their healthcare team to make a decision right for them

• Are more likely to follow through on their decision

National Learning Consortium. Shared decision making. 2013. (www.healthit.gov/sites/default/files/nlc_shared_decision_making_fact_sheet.pdf). Accessed 2/11/2020.

20

Implementing SDM in Practice

Invite the patient to participate

Present options

Provide information on benefits and risks

Assist patients in evaluating options based on their goals and concerns

Facilitate deliberation and decision‐making

Assist patients to follow through on the decision

National Learning Consortium. Shared decision making. 2013. (www.healthit.gov/sites/default/files/nlc_shared_decision_making_fact_sheet.pdf). Accessed 2/11/2020.

Current and Evolving Treatments for MS

21

Therapeutic Landscape of MS: 2020

In phase 3FDA‐approved therapies

2009 2010 201120061993 2002

IFNβ‐1b(Extavia®)

natalizumab(Tysabri®)

IFNβ‐1b(Betaseron®)

glatiramer acetate

(Copaxone®)

IFNβ‐1a(Avonex®)

IFNβ‐1a(Rebif®)

mitoxantrone(Novantrone®)

cladribine(Mavenclad®)

2012

ocrelizumab(Ocrevus®)

dalfampridine(Ampyra®)

dextromethorphan/quinidine(Nuedexta®)

2013

IFNβ‐1a(Plegridy®)

2014 20151996 1997 2000 2016 2017 2018

fingolimod(Gilenya®)

Symptomatic therapies Withdrawn from market

dimethyl fumarate(Tecfidera®)

teriflunomide(Aubagio®)

alemtuzumab(Lemtrada®)

glatiramer acetate

(Glatopa®)

daclizumab(Zinbryta®)

siponimod(Mayzent®)

2019

diroximel fumarate

(Vumerity®)

generic fingolimod(3)

IFNϐ = interferon beta.

2020

ozanimod(Zeposia®)

ponesimod

ofatumumab

Injectable DMTs

• Interferonβ:

– INFβ‐1b SC

– INFβ‐1a IM

– INFβ‐1a SC

– Pegylated INFβ‐1a SC

• Glatiramer acetate

– QD and TIW formulations

– Three products in US

• Attributes

– Long‐term experience

– Minimal safety and modest tolerability concerns

– Safest DMTs for use prior to pregnancy

Cocco E, et al. Mult Scler. 2015;21:433‐441. Jokubaitis VG, et al. Ann Neurol. 2016:80:89‐100. Cree BA, et al; University of California, San Francisco MS‐EPIC team. Ann Neurol. 2016;80:499‐510. Comi G, et al. Lancet. 2017;389:1347‐1356.

SC = subcutaneous; IM = intramuscular; QD = once a day; TIW = three times a week; RCT = randomized controlled trial.

22

Fingolimod: Efficacy of 0.5‐mg Dose in RCT

• FREEDOMS4

– Sustained low ARR; reduction in MRI activity and rate of brain volume loss in those on continuous fingolimod

– Reduction in relapse rates and MRI activity, including rate of brain volume loss, in those switching from placebo to fingolimod

• TRANSFORMS5

– Sustained low ARR (0.16) and MRI activity on continuing fingolimod

– 50% reduction in ARR (0.20) and MRI activity in those switching from IFNβ to fingolimod

• PARADIGMS6

– Superior to IFNβ‐1a in pediatric MS

– ARR 0.12 vs 0.67 over up to 2 years

1. Kappos L, et al. N Engl J Med. 2010;362:387‐401. 2. Cohen JA, et al. N Engl J Med. 2010;362;402‐415; 3. Calabresi PA, et al. Lancet Neurol. 2014;13:545‐556. 4. Kappos L, et al. Neurology. 2015;84:1582‐1591. 5. Cohen JA, et al. J Neurol Neurosurg Psychiatry. 2016;87:468‐475. 6. Chitnis T. N Engl J Med. 2018;379:1017‐1027.

Fingolimod 0.5‐mg dose efficacy in 3 RCTs1–3

Fingolimod sustained efficacy

in RCT extension trials

0

0.05

0.1

0.15

0.2

0.25

0.3

0.35

0.4

0.45

TRANSFORMS FREEDOMS FREEDOMS II

IFNβ‐1a IM or Placebo 0.5 mg (approved dose)

Annualized relapse rate

54% 48%48%

TRANSFORMS, FREEDOMS, and FREEDOMS II

ARR = annualized relapse rate.

Fingolimod: Safety Potential adverse effects (AEs)• Cardiovascular

– First‐dose observation 6 hours

– Caution regarding use in patients with CVD, prolonged QTc, or concomitant meds with potential to cause cardiac arrhythmia or decrease in BP

– ECG at start and end of observation; new heart block, arrhythmia, or symptomatic bradycardia requires further observation

• Macular edema – ↑risk w/diabetes, uvei s, cataract surgery

• Hepatotoxicity

• Infections: – Respiratory, tract

– Herpetic—must have VZV immunity

– PML

– Cryptococcus

• Avoid live‐virus vaccinations

• Pulmonary effects: reductions FEV1 and DLCO

• Subsequent increase in BP/hypertension

• Rebound following discontinuation

Cardiac contraindications• Recent (within 6 months)

– Myocardial infarction

– Unstable angina

– Cerebral vascular accident, transient ischemic attack

– Decompensated heart failure requiring hospitalization or Class III/IV heart failure

• History of Mobitz type II second‐degree or third‐degree AV block or sick sinus syndrome, unless patient has pacemaker

• Baseline QTc ≥500 ms

• Treatment with class Ia or class III antiarrhythmic drugs

FIngolimod (Gilenya®) prescribing information (PI) 2019 (www.pharma.us.novartis.com/sites/www.pharma.us.norvartis.com/files.gilenya.pdf ). Comi G, et al. Lancet. 2017;389:1347‐1356. FDA 2012 safety announcement (www.fda.gov/Drugs/DrugSafety/ucm303192.htm). Hatcher SE, et al. JAMA Neurol. 2016;73:790‐794. URLs accessed on 2/11/2020.

CVD = cardiovascular disease; BP = blood pressure; ECG = electrocardiogram; VZV = varicella zoster virus; PML = progressive multifocal leukoencephalopathy; FEV = forced expiratory volume; DLCO = diffusion lung capacity for carbon monoxide; AV = atrioventricular.

23

EXPAND: Siponimod (Selective S1P1R/ S1P5R) vs Placebo in Secondary Progressive MS

Kappos L, et al. Lancet. 2018:391:1263‐1273.

MeasureResult

Reduction/Improvement vs Placebo

P-value

Primary endpoint

3-month confirmed disability progression 21.0% reduction .013

Secondary endpoints

6-month confirmed disability progression 26.0% reduction .006

Annualized relapse rate 55.5% reduction <.0001

T1 Gd+ lesion number 86.6% reduction <.0001

New T2 lesion number 81.0% reduction <.0001

T2 lesion volume change from baseline 79.1% reduction <.0001

12-item MS walking scale 39.7% improvement <.0001

Percent brain volume change 23.4% improvement <.0001

Gd = Gadolinium.

Siponimod: Safety

• Prescreen

– CYP2C9 genotype determination

– CBC (+diff), LFTs (transaminase, bilirubin levels), VZV, IgG

– Ophthalmologic evaluation (macular edema)

– EKG

• First‐dose monitoring limited to pre‐existing cardiac conditions

– Sinus bradycardia (<55)

– 1st‐ or 2nd‐degree heart block

– H/O MI, heart failure

CYP2C9 = cytochrome P450 2C9; CBC = complete blood (cell) count; LFT = liver‐function test; EKG = electrocardiogram; H/O = history of; MI = myocardial infarction.

Siponimod (Mayzent®) PI, 2019. (www.pharma.us.novartis.com/sites/www.pharma.us.novartis.com/files/mayzent.pdf). Accessed 2/12/2020.

24

Siponimod: Safety(continued)

• Infections

• Bradyarrhythmia, AV conduction delay

• Respiratory effects

• Liver injury

• Hypertension

• Posterior reversible encephalopathy syndrome (PRES)

• Rebound

Siponimod (Mayzent®) PI, 2019. (www.pharma.us.novartis.com/sites/www.pharma.us.novartis.com/files/mayzent.pdf). Accessed 2/12/2020.

Ozanimod: Approved 3/26/20 for RRMS

• Ozanimod is 2nd generation S1P‐R modulator

– S1P‐R 1 and 5 specificity

– 0.92 mg capsule PO daily (titrate 0.23 mg days 1‐4, 0.46 mg days 5‐7)

– Ozanimod (6%) T ½ 21 hours

– Major active metabolites CC112273 (73%) and CC1084037 (15%) (T ½ 11 days)

– Ozanimod + 2 major metabolites account for 94% (3 minor active metabolites)

• Label recommends CBC + diff, liver panel, VZV antibodies; EKG, cardiac evaluation for pre‐existing conditions, ophthalmic assessment for h/o uveitis, macular edema

• Contraindicated with severe untreated sleep apnea; MAO inhibitor; prior 6 months MI/unstable angina/stroke/TIA/CHF requiring hospitalization; significant heart block or SSS without pacemaker

• 3 month washout for pregnancy

• Avoid strong CYP2C8 inducer (rifampin); not recommended with CYP2C8 inhibitor (gemfibrozil), and BCRP inhibitor (cyclosporine)

Ozanimod (Zeposia™) PI 2020 (https://packageinserts.bms.com/pi/pi_zeposia.pdf).

25

Ozanimod: Efficacy/Safety

• Phase 3 SUNBEAM trial

– Randomized, double blind, double dummy

• Enrolled N=1,346 RMS patients

– Evaluated PO ozanimod 0.5 mg, 1 mg vs IM IFNβ‐1a 30 mcg weekly over at least 12 months

• Both doses ARR (0.24, 0.18 vs 0.35), contrast lesions ( 34%; 63%), new/enlarging T2 lesions ( 25%/ 48%)

• Phase 3 RADIANCE (N=1,320) positive for both doses on relapse (ARR 0.22, 0.17 vs 0.28), MRI atrophy vs IM IFNβ‐1a ( 25%/ 27%)

• No pooled confirmed EDSS 3 mos disability

• Most common Aes: URTI, transaminase, BP issues, UTI, upper abdominal pain

Ozanimod (Zeposia™) PI 2020 (https://packageinserts.bms.com/pi/pi_zeposia.pdf). Celgene Announces Positive Results from Phase III SUNBEAM Trial of Oral Ozanimod in Patients with Relapsing Multiple Sclerosis [news release];Summit, NJ;Celgene;2017; http://ir.celgene.com/releasedetail.cfm?releaseid=1012395;April 25, 2017.

Teriflunomide: Clinical Efficacy

• TEMSO1

– 31.2% (7 mg), 31.5% (14 mg) reduction in ARR vs placebo

– Reduced risk of relapse over 2 years by 24% (46.3% vs 55%) for 7‐mg dose and 28% (43.5% vs 55%) for 14‐mg dose

– Reduced risk of EDSS↑ confirmed at 12 weeks by 30% for 14‐mg dose

• TOWER2

– 22% (7 mg), 36% (14 mg) reduction in ARR vs placebo

– Reduced risk of EDSS↑ confirmed at 12 weeks by 32 % for 14‐mg dose

1. O’Connor P, et al N Engl J Med. 2011;365:1293‐1303. 2. Confavreux C, et al. Lancet Neurol. 2014;13:247‐256.

Teriflunomide for RMS trial: TEMSO1

(N = 1088, 108‐week trial)

2.5

2.0

1.5

1.0

0.5

0

ARR ↓ 31%–32%

↓29.8% inprogression14‐mg group

↓48% and 69%In active MRIlesions

Annual relapse rate

Confirmed EDSS

worsening

Combined unique active MRI lesions

RMS = relapsing MS.

26

Teriflunomide: Safety/Tolerability

• GI: nausea, diarrhea

• Hair thinning (6 months)

• Hepatotoxicity—ALT

– Monthly LFTs for first 6 months

• Teratogenicity (animal models)

• Slow clearance from body; accelerated elimination and blood levels available (<0.02 µg/mL)

• Hypertension

• Rare: peripheral neuropathy, cutaneous reactions (SJS, TEN), interstitial lung disease

• TB screening prior to use

O’Connor P, et al. N Engl J Med. 2011;365:1293‐1303. Teriflunomide (Aubagio®) PI , 2019 (http://products.sanofi.us/aubagio/aubagio.pdf). Accessed 2/11/2020.

GI = gastrointestinal; ALT = alanine aminotransferase; SJS = Stevens‐Johnson syndrome; TEN = toxic epidermal necrolysis; TB = tuberculosis.

Dimethyl Fumarate (DMF): Efficacy

Clinical efficacy: DMF 240 mg BID DMF MRI efficacy: 240 mg BID

• Reduced mean number new/increased T2 lesions

– 85% vs placebo in DEFINE

– 71% in CONFIRM

• Reduced mean number new T1 hypointense lesions by 57% vs placebo in CONFIRM

• % of patients free of new/increased T2 lesions over 2 years was 27% for DMF vs 12% for placebo in CONFIRM.

• % of patients free of new T1 hypointense lesions was 39% for DMF vs 21% for placebo in CONFIRM.

Gold R, et al. N Engl J Med. 2012;367:1098‐1107. Fox RJ, et al. N Engl J Med. 2012;367:1087‐1097.

Reduc on in risk of EDSS ↑ was confirmedat 12 weeks by 38% in DEFINE, but no significant reduction was found in CONFIRM.

Study not powered to show differences between GA and DMF; differences between these arms were not statically significant

Relapse at 2 years (%) ARR at 2 years

DMF

Placebo

GA

DEFINE

50%

CONFIRM

40%

30%

20%

10%

0%DEFINE

0.45

CONFIRM

0.400.350.300.250.200.150.100.05

0

GA = glatiramer acetate; BID = twice daily.

27

Dimethyl Fumarate: Safety/Tolerability

• GI: abdominal pain, nausea, emesis, and diarrhea (transient)

• Flushing (transient), mitigated by taking with meals, ASA prior

• Proteinuria

• Rash/pruritus

• Lymphopenia

– 7 PML case reports in MS patients post marketing

– Lymphopenia in 4%–5% of patients in clinical trials; 2.2% <500/mm3 for >6 mos

– If ALC <800/mm3 in 1st year, risk of ALC <500/mm3 for >6 mos = 11%

– Persistent lymphopenia up to >30 mos, associated with duration exposure

– No association of lymphopenia with efficacy or infections (except PML)

• Elevated transaminases in 6% in clinical trials

Gold R, et al. N Engl J Med. 2012;367:1098‐1107. Fox RJ, et al. N Engl J Med. 2012;367:1087‐1097. Ermis U, et al. N Engl J Med. 2013;368:1657‐1658. van Oosten BW, et al. N Engl J Med. 2013;368:1658‐1659.Sweetser MT, et al. N Engl J Med. 2013;368:1659‐1661. Fox RJ, et al. Neurol Clin Pract. 2016;6:220‐229. Khatri BO, et al. Mult Scler Relat Disord. 2017;18:60‐64.

ASA = aspirin; mos = months; ALC = absolute lymphocyte count.

Diroximel Fumarate (DRF) Agent

• Diroximel fumarate

– Novel aminoethyl ester of monomethyl fumarate

– Pro‐drug; modified release product

– 462 mg BID (2 capsules BID); can take without food (avoid high fat meals)

– Better GI tolerability ( food)

– EVOLVE‐MS‐1 phase 3 open label 2 yr safety study interim data indicates favorable safety/efficacy profile; EVOLVE‐MS‐2 5 wk head to head vs DMF on GI tolerability showed better GI side effects and tolerability

Diroximel fumarate (Vumerity™) PI 2019 (www.vumerity.com/content/dam/commercial/vumerity/pat/en_us/pdf/vumerity‐prescribing‐information.pdf). Naismith RT, et al. Mult Scler. 2019;Nov 4; Epub ahead of print. Naismith R, et al. Neurology. 2018;90(15 suppl):p6.360. Davio K. AJMC (www.ajmc.com/newsroom/fda‐approves‐diroximel‐fumarate‐to‐treat‐relapsing‐forms‐of‐ms). Both URLs accessed 2/11/2020.

28

Natalizumab (NTZ): Efficacy

Polman CH, et al. N Engl J Med. 2006;354:899‐910.

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1

Year 1 Year 2

68% relative risk reduction vs PBO42% reduc on in risk EDSS ↑ confirmed at 12 weeks

Kaplan‐Meier plots of time to sustained progression of disability among patients receiving natalizumab, compared with placebo.

Proportion of patients with

sustained progression of disab

ility

P<0.001Placebo

Natalizumab

Weeks

0.4

0.3

0.2

0.1

0.0

No.at risk

NatalizumabPlacebo

0 12010896847260483612 24

315 199200208216229240248264296 283627 473478490503517525546567601 582

Annualized relapse rate

PBO = placebo; HR = hazard ratio; CI = confidence interval.

Natalizumab reduced risk of sustained progression of disability by 42% over 2 years (HR = 0.58; 95% CI, 0.43–0.77). Cumulative probability of progression was 17% in natalizumab group and 29% in placebo group.

NTZPBO

NTZ: Safety

• Hypersensitivity reactions/neutralizing antibodies

• Rare hepatotoxicity

• PML

– JCV ab test = biomarker for risk stratification

• Potential for seroconversion requires periodic testing

• Quantitative index offers further value in risk stratification

– Additional risk factors

• Duration of therapy

• Prior immune suppressive therapy (irrespective of duration of Rx or remoteness of exposure)

– Clinical and MRI monitoring for emergent PML is required while on therapy

• MRI every 3–6 months if JCV ab+, at least annually if JCV ab–

• Clinical and antibody evaluation every 3 months

– Consider extended dosing (Q6–8 weeks); risk of PML in TOUCH cohort

• CNS herpes virus infections, cryptococcal infections

• Reactivation/rebound in MS activity when discontinued

Polman CH, et al. N Engl J Med. 2006;354:899‐910. Kappos L , et al. Lancet Neurol. 2011;10:745‐758. Bloomgren G, et al. N Engl J Med. 2012;366:1870‐1880. Clifford DB, et al. Lancet Neurol. 2010;9:438‐446. Miravalle A, et al. Arch Neurol. 2011;68:186‐191. Traboulsee A, et al. AJNR Am J Neuroradiol. 2016;37:394‐401. Natalizumab (Tysabri®) PI 2019 (www.tysabri.com/content/dam/commercial/tysabri/pat/en_us/pdf/tysabri_prescribing_ information.pdf). Accessed 2/11/2020. Ryerson LZ, et al. Neurology. 2019;93:e1452‐e1462.

JCV = John Cunningham virus; ab = antibody.

29

Natalizumab‐Associated PML Risk1

• Berger and Fox3 suggest risk of 8/1000 for seropositive without prior immunosuppressive (IS) therapy and 23/1000 for seropositive with history of IS therapy treated for 25–48 months.

• A case report4 described an individual taking natalizumab who developed PML 2 weeks after a negative anti‐JCV antibody test.

1. Natalizumab (Tysabri®) PI 2019 (www.tysabri.com/content/dam/commercial/tysabri/pat/en_us/pdf/tysabri_prescribing_information.pdf). Accessed 2/11/2020. 2. Ho PR, et al. Lancet Neurol. 2017;16:925‐933. 3. Berger JR, Fox RJ. J Neurovirol. 2016;22;533‐535. 4. Gagne Brosseau MS, et al. Neurology. 2016;86:484‐486.

Negative

0.07/1000

NTZ Exposure NO YES

1–24 months <1/1000 patients 1/1000 patients

25–48 months 3/1000 patients 12/1000 patients

49–72 months 6/1000 patients 13/1000 patients

Positive

Anti‐JCV antibody status2

Prior IS use

Recent Data on Anti‐JCV Antibody Index and Natalizumab‐Associated PML Risk

Ho PR, et al. Lancet Neurol. 2017;16:925‐933.

Risk Estimates for Patients Receiving Natalizumab Who Have Never Received Prior IS Therapy

Infusion exposure Index ≤0.9 Index >0.9 to ≤1.5 Index >1.5

1–12 mos 0.01/1000 0.1/1000 0.2/1000

13–24 mos 0.06/1000 0.3/1000 1.0/1000

25–36 mos 0.2/1000 0.8/1000 2.8/1000

37–48 mos 0.4/1000 2.1/1000 7.1/1000

49–60 mos 0.5/1000 2.4/1000 8.2/1000

61–72 mos 0.6/1000 3.0/1000 10.2/1000

30

Alemtuzumab Clinical Efficacy in Early Active Relapsing Treatment‐Naïve Cohort

Cohen JA, et al. Lancet. 2012;380:1819‐1828.

Results of CARE MS‐1 Study

0

0.05

0.1

0.15

0.2

0.25

0.3

0.35

0.4

0.45

Alem

Rebif

ARR years 0–2 Confirmed disability at 6 mos (%)

0.39

0.18

P <.0001

54.9% risk reduction Non‐Significant11%

8%

P= .22

Alem = alemtuzumab; Rebif = interferon beta 1a.

Alemtuzumab Results in Cohort Breaking Through Treatment

Coles AJ, et al. Lancet. 2012;380:1829‐1839.

• Reduction in ARR = 49.6%

• Confirmed disability accumulation:

– 13% Alem vs 20% PBO (P=0.008)

– 42% reduction with Alem

• Increase in patients with confirmed disability improvement: 22% for Alem vs 9% for IFNβ‐1a

0.26

0.52

0

0.6

Alem

IFNβ

0.5

ARR

0.4

0.3

0.2

0.1

Results of CARE MS‐2 study

31

Alemtuzumab: Safety

• Infusion reactions

• Infections– Antiviral prophylaxis for HSV/VZV with each

treatment cycle

• Secondary autoimmunity – 47.7% (UK Cambridge cohort 1999–2012)

– Thyroid disease most common

– Immune thrombocytopenia

– Rare cases of antiglomerular basement‐membrane disease

• ? increased risk of malignancies – Thyroid

– Melanoma

– Lymphoproliferative disorders

• Risk‐management program– Certified infusion centers and prescribers

– Monthly CBC, UA for 48 months following last infusion

– Thyroid tests every 3 months for 48 months following last infusion

– Annual dermatologic exams

Alemtuzumab (Lemtrada®) PI 2019 (http://products.sanofi.us/Lemtrada/Lemtrada.pdf). Tuohy O, et al. J Neurol Neurosurg Psychiatry. 2015;86:208‐215. FDA press release, 11/29/18. (www.fda.gov/media/119052/download). Both URLs were accessed 2/11/2020.

HSV = herpes simplex virus; UK = United Kingdom; UA = urinalysis.

Boxed Warning

• Autoimmune conditions

• Infusion reactions

• Serious life‐threatening stroke within 3 days

• Increased risk of malignancies

Ocrelizumab—RRMS OPERA I/IIClinical Outcomes1

OutcomesOcrelizumab vs

IFNβ-1a SCRelative difference:

Ocrelizumab

ARR at 96 weeks (primary endpoint)

OPERA I 0.16 vs 0.29 46% (P <.001)

OPERA II 0.16 vs 0.29 47% (P <.001)

EDSS ↑ confirmed at 12 weeks* 9.1% vs 13.6% 40% (P <.001)

EDSS ↑ confirmed at 24 weeks* 6.9% vs 10.5% 40% (P= .003)

EDSS ↓ confirmed at 12 weeks* 20.7 % vs 15.6% 33% (P =.02)

NEDA at 96 weeks: ocrelizumab

OPERA I 47.9% vs 29.2% non-confirmatory due to hierarchical analysisOPERA II 47.5% vs 25.1%

1. Hauser SL, et al. N Engl J Med. 2017;376:221‐234. 2. September 2019 press release. (www.roche.com/media/releases/med‐cor‐2019‐09‐13b.htm). Accessed 2/11/2020.

*Pooled Data

6‐year extension data2

• Continued efficacy• Disability worsening less with early treatment vs IFNβ switchers

32

Ocrelizumab for Treating Progressive MS

• First agent approved for use in PPMS

• 24%–25% reduction in risk of progression as measured by EDSS change (? no impact in women)

• 6.5‐year follow‐up data showed durable benefit on EDSS & 9 Hole Peg test for those starting ocrelizumab vs those starting placebo and switching to ocrelizumab at open‐label extension

• Patient cohort was relatively young (<55 years), recently worsening, had positive CSF oligoclonal bands, and was relatively healthy other than MS

• Design of study informed by prior rituximab primary progressive study that failed to show benefit on disability progression; however, post‐hoc analysis showed suggestion of efficacy in younger patients with active MRI lesions

• How well do these data generalize to the real‐world population with PPMS who would not meet these criteria?

Montalban X, et al. N Engl J Med. 2017;376:209‐220; Hawker K, et al. Ann Neurol. 2009;66:460‐471; Wolinsky JS. ECTRIMS 2019; Abstract 159.

PPMS = primary progressive MS.

ORATORIO: Ocrelizumab vs Placebo for Treatment of Primary Progressive MS

Montalban X, et al. N Engl J Med. 2017;376:209‐220.

Ocrelizumab vs Placebo

Relative Difference

Disability progression confirmed at 12 weeks (primary endpoint)

32.9% vs 39.3%24% ↓ P= .03

Disability progression confirmed at 24 weeks

29.6% vs 35.7%25% ↓ P= .04

Mean % change in 25-foot walk, baseline to week 120

38.9% vs 55.1%29.3% ↓ P= .04

Adjusted Mean % change in total T2 lesion volume, baseline to week 120

–3.37% vs +7.43% P <.001

Mean change in brain volume, week 24–120

–0.90% vs –1.09% P= .02

33

Ocrelizumab: Safety

• Infusion reactions in 34%–40% in clinical trials, most frequent and severe with early infusions but could occur at any infusion1,2

• Infection rates similar in ocrelizumab and IFNβ‐1a groups1

– Serious infections with ocrelizumab less frequent

• Infection rates more common than with placebo in ORATORIO1,2

– URI and nasopharyngitis most common

• Malignancies numerically more common with ocrelizumab

– 0.4 vs 0.2/100 patient‐years for comparators across all trials1

– OPERA I/II: 4 compared to 2 with IFNβ, 5 additional during OLE1

– ORATORIO: 11 (2.3%) with ocrelizumab vs 2 (0.8%) with placebo; 2 additional cases during OLE2

1. Hauser SL, et al. N Engl J Med. 2017;376:221‐234; 2. Montalban X, et al. N Engl J Med. 2017;376:209‐220.

URI = upper respiratory (tract) infection; OLE = open‐label extension.

Cladribine

• Intracellular accumulation of metabolite 2‐chlorodeoxyadenosine, triphosphate disrupts cell metabolism, inhibits DNA synthesis, and causes apoptosis

• 2

• Selective effect on lymphocytes due to limited adenosine deaminase activity

• Induction agent: prolonged effect on T lymphocytes, more transient effect on B lymphocytes

• Two annual courses of 3.5 mg/kg given over 5 days in 2 cycles (2 successive mos) for 2 years

• Reduced ARR by 57.6% vs PBO (0.14 vs 0.33, P <.0001), increased % relapse free (79.7% vs 60.9%), and decreased % with 3‐month confirmed disability progression by 33%

• Adverse events: lymphopenia, increased infections, herpes zoster

• Efficacy maintained in years 3 and 4

Giovannoni G, et al. N Engl J Med. 2010;362:416‐426. Giovannoni G, et al. Mult Scler. 2018;24:1594‐1604. Stuve O. ECTRIMS, 2017, poster 667 (https://onlinelibrary.ectrims‐congress.eu/ectrims/2017/ACTRIMS‐ECTRIMS2017/200322/olaf.stuve.effects.of.cladribine.tablets.on.cd42B.t. cell.subsets.in.the.html). Accessed 2/11/2020.

DNA = deoxyribonucleic acid.

34

Emerging Agents

Emerging Agents

• Anti‐CD20s

– Ofatumumab: human anti‐CD20, 20 mg SC monthly; ASCLEPIOS I and II completed; superior to teriflunomide

– Ublituximab: glycoengineered chimeric anti‐CD20, 450 mg IV Q6 months; ULTIMATE I and II phase 3 trials recruited (vs teriflunomide)

• S1P receptor modulators

– Ponesimod: S1P‐R1; OPTIMUM trial found ponesimod to be superior to teriflunomide 20 mg; N = 1333; ARR 0.202 vs 0.290; fatigue; disability not significant; POINT trial evaluating DMF/placebo vs DMF/ponesimod ongoing

35

Emerging Agents(continued)

• CNS‐repair strategies

– High‐dose biotin (100 mg 3x daily); phase III trial failed

– Oral clemastine

– IV opicinumab (mAb to LINGO‐1); AFFINITY phase 2 trial

– Gold nanoparticles

– Stem cell therapy

• Ibudilast

• α lipoic acid

mAb = monoclonal antibody.

AAN Guidelines: Initiating Therapy: Level A/B

• Counsel patients on DMT at dedicated treatment visit

• Discuss and incorporate patient preferences in DMT decision; maintain ongoing dialogue

• Educate patients on realistic DMT expectations; communicate new/worsening symptoms

• Evaluate patient readiness for DMT and counsel on its value

• Counsel on effects of comorbidities and adverse health behaviors on MS course

• Evaluate barriers to adherence and counsel on its importance

• Discuss and prescribe DMTs for CIS with >2 brain lesions characteristic of MS

• Offer DMT to patients with relapsing forms of MS and recent relapse or MRI activity

Rae‐Grant A, et al. Neurology. 2018;90:777‐788 [AAN practice guideline recommendations summary: DMT for adults with MS]

AAN = American Academy of Neurology.

36

AAN Guidelines: Initiating Therapy: Level A/B(continued)

• Monitor for DMT AEs, efficacy, tolerability, and adherence

• Monitor pregnancy plans and counsel regarding risks and contraception while on DMT

• Counsel men regarding teriflunomide or cyclophosphamide reproductive risks before initiating

• Do not use mitoxantrone unless potential therapeutic benefits greatly outweigh risks

• Prescribe alemtuzumab, fingolimod, or natalizumab for patients with highly active MS

• Offer ocrelizumab to patients with primary progressive MS likely to benefit, unless risks outweigh benefits


Monitoring Treatment Efficacy

• Clinical for relapse or worsening

– Relapses while on treatment decrease time to progressive MS

– Relapses in progressive MS increase disability progression

• MRI for new disease activity

– MRI definition of suboptimal response: ? lesion number, ? serial accumulation

– Threshold for new MRI T2 lesions may vary with therapeutic agents

– CombiRx: activity on MRI at 3 years did not predict risk of worsening over up to 7 years of follow‐up

– Timing of reference scans, 3–6 months after starting new agent

– Monitoring changes in brain volume? NEDA‐4

• Setting treatment targets

Lizak N, et al. J Neurol Neurosurg Psychiatry. 2017;88:196‐203. Rush CA, et al. Nat Rev Neurol. 2015;11:379‐389. Paz Soldán MM, et al. Neurology. 2015;84:81‐88. Traboulsee A, et al. AJNR Am J Neuroradiol. 2016;37:394‐401. Lublin FD, et al. Mult Scler Relat Disord. 2017;18:95‐102. Rae‐Grant A, et al. Neurology. 2018;90:777‐788.

NEDA‐4 = 4 no evidence of disease activity (criteria).

37

AAN Guidelines: Switching Therapy: Level A/B

• Discuss switching DMT in patients experiencing relapses, increased disability, or >2 unequivocal new lesions over a 1‐year period in patients adherent to DMT

• Evaluate MS activity, adherence to DMT, AE profile, and mechanism of action when switching for breakthrough activity

• Discuss switch to non‐injectable DMT for injection discomfort or fatigue

• Inquire about DMT AEs and switch if they affect adherence

• Monitor laboratory abnormalities and discuss switch if persistent

• Counsel on PML risk for relevant DMTs, and discuss switch to DMT with lower PML risk in natalizumab patients with JCV Ab index >0.9


Ab = antibody.

AAN Guidelines: Switching Therapy: Level A/B(continued)

• Counsel that new DMTs have undefined risks for malignancy and infection; switch DMTs for serious infections and discuss switch if malignancy develops

• Check for natalizumab antibodies (NAbs) in patients with infusion reactions or breakthrough activity; switch if persistent NAbs

• Counsel on increased risk of MS relapse and MRI activity within 6 months of discontinuing natalizumab; initiate fingolimod if used as alternative DMT within 8–12 weeks

• Counsel women to stop DMT before pursuing conception or if accidental pregnancy exposure, unless risk of relapse during pregnancy outweighs risk of DMT during pregnancy


38

Thank you!

Multiple Sclerosis: Diagnosis and Management

Resource Address

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Brownlee W, et al. Diagnosis of multiple sclerosis: progress and challenges. Lancet. 2017;389:1336-1346.

https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)30959-X/fulltext

Dargani N, et al. Multiple sclerosis: immunopathology and treatment update. Brain Sci. 2017;7:78.

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Eriksson I, et al. The changing multiple sclerosis treatment landscape: impact of new drugs and treatment recommendations. Eur J Clin Pharmacol. 2018;74:663-670.


Havas J, et al. Predictive medicine in multiple sclerosis: A systematic review. Mult Scler Relat Disord. 2020;40:101928.

https://www.sciencedirect.com/science/article/abs/pii/S2211034820300043

Karussis D. The diagnosis of multiple sclerosis and the various related demyelinating syndromes: a critical review. J Autoimmun. 2014;48-49:134-142.

https://www.sciencedirect.com/science/article/pii/S0896841114000250

Marcus JF, et al. Updates on clinically isolated syndrome and diagnostic criteria for multiple sclerosis. Neurohospitalist. 2013;3:65-80.


Ruiz F, et al. Resolution of inflammation during multiple sclerosis. Semin Immunopathol. 2019;41:711-726.


Simon JH. MRI outcomes in the diagnosis and disease course of multiple sclerosis. Handb Clin Neurol. 2014;122:405-425.

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Sormani MP, et al. Can we measure long-term treatment effects in multiple sclerosis? Nat Rev Neurol. 2015;11:176-182.

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Stys PK, et al. Recent advances in understanding multiple sclerosis. F1000Res. 2019;8:F1000.


Tanasescu R, et al. Advances in the treatment of relapsing-remitting multiple sclerosis. Biomed J. 2014;37:41-49.

http://biomedj.cgu.edu.tw/pdfs/2014/37/2/images/BiomedJ_2014_37_2_41_130440.pdf

Thompson AJ, et al. Diagnosis of multiple sclerosis: 2017 revisions of the McDonald criteria. Lancet Neurol. 2018;17:162-173.

https://www.thelancet.com/journals/laneur/article/PIIS1474-4422(17)30470-2/fulltext

Toosy A, et al. Symptomatic treatment and management of multiple sclerosis. Handb Clin Neurol. 2014;122:513-562.

https://www.sciencedirect.com/science/article/pii/B9780444520012000236

Visser LA, et al. Patient needs and preferences in relapsing-remitting multiple sclerosis: A systematic review. Mult Scler Relat Disord. 2020;39:101929.

https://www.msard-journal.com/article/S2211-0348(20)30005-5/fulltext

Resources and Societies

Resource Address American Academy of Neurology https://www.aan.com Consortium of Multiple Sclerosis Centers http://www.mscare.org Multiple Sclerosis Association of America http://www.mymsaa.org Multiple Sclerosis Foundation http://www.msfocus.org National Institute of Neurological Disorders and Stroke

http://www.ninds.nih.gov/index.htm

National Multiple Sclerosis Society http://www.nationalmssociety.org

https://www.aan.com/

http://www.mscare.org/

http://www.mymsaa.org/

http://www.msfocus.org/

http://www.ninds.nih.gov/index.htm

http://www.nationalmssociety.org/

You can view these videos again by typing in the link below or scanning the QR codes with your smart phone camera app. Make sure you have the YouTube application installed.

MS Pathology

https://youtu.be/Kg1ukVuzGhI

MS Treatment

https://youtu.be/41RcSyf3LxQ

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A VIRTUAL REALITY VIEW

Selecting Disease-Modifying Therapy for Multiple Sclerosis: Tools to Achieve and Maintain Control

of a Dynamic Disease

a virtual reality view selecting disease-modifying therapy ... · 26/05/2020 · the reviewer of...

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