Archive for ‘MS Research News’
Our immune system includes a type of cell called lymphocytes. T lymphocytes target other cells such as cells infected with viruses or cancerous cells. They are called “T” cells since they mature in the thymus gland in the upper chest. Normally T cells that would attack our own cells are destroyed in the thymus gland before being released into the circulation. In autoimmune diseases such as multiple sclerosis, these T cells escape and can lead to the immune attack on myelin.
B cells mature in the bone marrow in humans, but were named after a specialized organ where B cells mature in birds known as the bursa of Fabricius. B cells can change into plasma cells which make antibodies. Antibodies are like targeted arrows that can help attack germs such as viruses or bacteria that are invading our bodies. In multiple sclerosis, B cells turn against their human by creating antibodies that attack myelin and revving up autoimmune T cells.
Role of T and B cells in Vaccination:
Vaccines work by imitating a serious infection. Vaccines can cause minor symptoms, but do not cause the actual disease. The vaccine triggers the development of specific-targeted T and B cells that remember the infection. When someone is then exposed to the real life-threatening virus or bacteria in the future, they can mount a highly effective defense against the infection due to these “memory” T and B cells. For example, children are vaccinated with a weakened, live chicken pox virus called the varicella-zoster virus. The immune system then develops T cells and antibodies specific for this varicella virus. The vaccine has been shown reduce the risk of getting chicken pox later in life by 92%. If someone is immunosuppressed, important to avoid live, weakened (attenuated) viruses.
Most vaccines are inactivated vaccines which means they do not contain live viruses or bacteria. Vaccines that inject killed whole virus include polio, hepatitis B and rabies. Many inactivated vaccines include only sugar molecules (polysaccharides) that are found on the surface of bacteria or surface proteins that are found on viruses. These components of the infectious agent lack the ability to replicate since they do not contain disease-spreading genetic material (RNA or DNA).
For COVID-19, the Pfizer and Moderna vaccines are mRNA vaccines. The mRNA contains instructions for our own body to make a harmless “spike” protein. This spike protein is on the surface of the COVID-19 virus. The spikes on the surface of this COVID-19 coronavirus creates a “corona” (derived from the latin word for crown). The mRNA is surround by a lipid (fatty) nanoparticle that allows it to enter cells of the body when injected in the muscle. Once mRNA is in the cells, the cells can create their own spike proteins on their surface. The body’s immune system that reacts to these foreign spike proteins leading to immunity with memory T and B cells. These COVID-19 vaccinations result in a robust immune response to this spike protein that provides up to 95% immunity from the real COVID-19 infection, caused by the SARS-CoV-2 virus.
The AstraZeneca and Sputnik V vaccines use a type of virus called an adenovirus to insert DNA into the cell nucleus. The double-stranded DNA does not get into our own DNA, however. The DNA strand allows the cell to also make only the spike protein. The DNA in the adenovirus has been altered so the adenovirus lacks to the ability to replicate (divide) in the body.
Disease-Modifying Therapies (DMTs) and Response to Vaccines:
All decisions regarding taking a vaccine with multiple sclerosis should be made in consultation with your healthcare providers.
Multiple sclerosis medications can impact your body’s ability to mount an immune response to a vaccine. Most trials looking at responses to vaccines in MS patients measure antibodies in the blood which is driven by B cell immune response. You may be able to mount an effective T cell response to a virus, but much harder to measure. Different MS medications (DMTs) might weaken your ability to develop a protective level of immunity from a vaccine. In a study of 152 people performed in Norway, protection against H1N1 flu virus at 6 months post-vaccination occurred in 86% of those MS patients treated with Copaxone (glatiramer acetate), 84% of patients on interferon, 58% on Gilenya (fingolimod) and 75% on Tysabri (natalizumab) and 94% of healthy people not on MS medications.
Live, weakened virus vaccines should be avoided on many multiple sclerosis DMTs including Ocrevus (ocrelizumab), Kesimpta (ofatumumab), Gilenya (fingolimod), Mayzent (siponimod), Zeposia (ozanimod) and Mavenclad (cladribine) per their prescribing information. At this point, the leading vaccines for COVID-19 do not contain live, replicating virus. The impact of each DMT on the protective response to COVID-19 vaccination is unknown. Both antibodies and T cell responses likely play a role in being fully vaccinated again the COVID-19 virus.
Below are some of the trials that have looked at vaccine responses to DMTs (Link for full review):
Aubagio (teriflunomide): The TERIVA trial examined flu vaccine responses to both Aubagio and interferon beta-1. Effective vaccination based on antibodies was 97% to the flu-vaccine for H1N1 and B strains and 77% for H3N2.
Tecfidera (dimethyl fumarate): In another study of 71 MS patients (38 on Tecfidera and 33 on interferon), antibody response to specific pneumococcal strain vaccines was 84-95% on Tecfidera and 88-97% on interferon. 47% of MS patients on Tecfidera and 42% of patients on interferon made protective antibody levels at 4 weeks to a meningococcal vaccine.
Gilenya (fingolimod): A trial of 138 MS patients randomized to placebo or Gilenya for 12 weeks to examine response to a seasonal flu vaccine. 54% of MS patients at 3 weeks after the flu vaccine mounted a protective antibody response on Gilenya while 85% on placebo. At 6 weeks post-vaccination, 43% of Gilenya-treated patients made a response but 75% on placebo.
Interferons (class includes Avonex, Betaseron (Betaferon), Rebif, Extavia and Plegridy): As above, the TERIVA trial examined flu vaccine responses to both interferon beta-1 and Aubagio. Effective flu vaccination based on antibodies occurred in 91-98% of multiple sclerosis patients depending on the flu strain.
Mayzent (sipinomod): Flu vaccination was studied prior to Mayzent treatment, during treatment and with treatment interruption in 120 healthy volunteers. For Influenza A California strain, protective antibody levels occurred in 86.7% of subjects on placebo, 92.9% vaccinated preceding Mayzent, 74.1% during Mayzent treatment and 71.4% with interrupted Mayzent treatment. For Influenza B Massachusetts strain, response rates were much less: 43.3% on placebo, 50.0% preceding, 25.9% during and 28.6% on interrupted Mayzent treatment. 100% of subjects immunized with pneumococcal vaccination prior or during Mayzent 2 mg treatment mounted protective antibody levels.
Ocrevus (ocrelizumab): In the VELOCE trial, MS patients exposed to various vaccines were studied. Flu-virus antibody responses were 56% to 80% on Ocrevus while 75-90% on placebo or interferon. In addition, antibody response rates to pneumococcal vaccination was reduced. Antibody (humeral) responses to vaccines rely on B cells and plasma cells.
Feb 29 2020 Living with MS in Coronavirus COVID-19 Pandemic
MS Living Well values educating people living with MS globally since 2007. In this developing coronavirus pandemic, the goal is provide information specific to those living with MS to help determine your risks and ways to protect yourself. For more info see the CDC’s website on COVID-19.
EVALUATE YOUR RISK:
A. LOCATION: plays a major factor. Higher risk countries are changing: now Europe, United States and Iran have the most new cases (updated March 19, 1920). The situation is changing rapidly so important to be aware of local evolving risk. Many people may be carriers of the virus without symptoms. People can become infected if within 6 feet of someone infected with the coronavirus who coughs or sneezes or by touching surfaces infected and then touching your face, nose or possibly your eyes.
B. IMMUNE STATUS: Many multiple sclerosis medications could put a person at increased risk of serious complications from coronavirus infection including pneumonia or even death. All FDA-approved medications to change the disease course of multiple sclerosis impact the immune system. As a consequence, your ability to fight the viral infection may not be as robust. Many MS medications have been studied to make sure that people can still mount an immune response to new virus while the medication is being taken.
Ocrevus, Gilenya and Mayzent have been associated with an increased risk of respiratory infections in clinical trials and might make MS patients on these medications at increased risk of coronavirus complications. Lemtrada and Mavenclad could also potentially put people with MS at higher risk of serious complications during the year after the last treatment course. Whether Tecfidera, Vumerity or Tysabri treatment would impact susceptibility to coronavirus complications is unclear. Teriflunomide is likely low risk for increased complications. Copaxone and interferons (Avonex, Betaseron, Extavia, Plegridy and Rebif) are likely quite safe as well. NEVER STOP YOUR MS MEDICATION ON YOUR OWN SINCE COULD LEAD TO PERMANENT SEVERE DISABILITY. ALWAYS CONSULT WITH YOUR HEALTHCARE PROVIDERS BEFORE MAKING TREATMENT DECISIONS.
C. AGE and DISABILITY: Elderly patients are at greater risk of death. Overall, the risk of death is estimated at 2-3% of infected COVID-19 patients. People with MS with higher levels of disability such as with moderate to severe weakness in arms and legs may be more vulnerable to coronavirus complications.
A. Avoid close contact with people who are sick.
B. Avoid touching your eyes, nose, and mouth.
C. Cover your cough or sneeze with a tissue, then throw the tissue in the trash.
D. Clean and disinfect frequently touched objects and surfaces using a regular household cleaning spray or wipe. The virus can linger for a few days on plastic and steel.
E. Facemasks are not recommended by the CDC for people that are healthy. N95 masks are effective but generally reserved for healthcare works treating sick coronavirus patients.
F. Wash your hands often with soap and water for at least 20 seconds, especially after going to the bathroom; before eating; and after blowing your nose, coughing, or sneezing. If soap and water are not readily available, use an alcohol-based hand sanitizer with at least 60% alcohol.
G. Stock up on supplies at home if you are at higher risk for complications. As infection rates soar, you will be prepared to avoid public places for shopping.
H. Would avoid travel including airplane flights and cruises. Avoid attending group gatherings such as meetings, religious events and sporting events in higher risk areas.
I. Notify your healthcare providers immediately if having fever, cough or shortness of breath.
Oct 30 2019 Vumerity: New Oral MS Medication FDA-approved
Vumerity is a twice a day oral medication for patients with multiple sclerosis. The active ingredient of Vumerity is diroximel fumarate, which is rapidly converted to monomethyl fumarate in the body. Similarly dimethyl fumarate (Tecfidera) is also converted to monomethyl fumarate. Therefore, Vumerity would be expected to the same benefits as Tecfidera on multiple sclerosis such as 53% reduction of relapses, 38% reduction in likelihood of disability progression and 90% reduction on active contrast MRI lesions (DEFINE trial).
Full results of the EVOLVE-MS trials are pending including the EVOLVE-MS-1 study, a Phase 3, open-label, two-year safety study and the EVOLVE-MS-2 study, a Phase 3, five-week randomized, prospective, double-blind, multi-center study that assessed the gastrointestinal (GI) tolerability of VUMERITY and TECFIDERA using self-administered GI questionnaires. Based on preliminary results of EVOLVE-MS-1 study that I presented at ECTRIMS in September 2019, approximately 30% of Vumerity had gastrointestinal side effect but less than 1% discontinue due to this side effect. Lymphocyte (type of white blood cell) monitor is important to reduce potential risk of PML, a brain viral infection. Thanks to all of our patients who participated in the clinical trials.
Mavenclad is an oral medication approved for relapsing-remitting and secondary progressive multiple sclerosis. The oral treatment course consists of two yearly courses of 2 cycles of 1-2 tablets per day for 4-5 days depending on the patient’s weight.
In the CLARITY study, 1326 multiple sclerosis patients were randomized to a total dose of 3.5 mg/kg (FDA-approved dose), 5.25 mg/kg or placebo. Mavenclad 3.5 mg/kg total dose reduced relapses by 58% compared to placebo. Likelihood of progression of disability was reduced by 33% on Mavenclad. On MRI, Mavenclad reduced contrast-enhancing lesions by 86% and new or enlarging T2 lesions by 73% compared to placebo.
Risks of Mavenclad include low white blood cell counts, serious infections, anemia, potential fetal harm and possible malignancy. Per prescribing information, use of MAVENCLAD is generally recommended for patients who have had an inadequate response to, or are unable to tolerate, an alternate drug indicated for the treatment of MS due to its safety profile.
Mayzent (siponimod) is a tablet medication to treat people with both relapsing-remitting multiple sclerosis and secondary-progressive patients with active disease such with new relapses or new MRI activity.
In the EXPAND trial, 1651 multiple sclerosis patients with secondary-progressive multiple sclerosis were randomized to once-daily oral Mayzent 2 mg daily or placebo for up to 3 years (2/3 of patients received Mayzent). Patients on Mayzent had a 21% less risk of disability progression than those patients on placebo. Mayzent reduced relapses by 55% compared to placebo. Patients on Mayzent were more likely to be free of contrast-enhancing lesions (89% vs 67% on placebo) and free of new or enlarging T2 lesions (57% vs. 37% on placebo).
Medication risks include elevation of liver blood test, swelling back of eye (called macular edema), increase in blood pressure and potential serious infections.
May 29 2017 A New Era of Multiple Sclerosis Treatment
Prior to 1993, no approved treatments were available for multiple sclerosis (MS). People who developed MS prior to the first treatments, unfortunately, had damage to their brain and spinal cords which often led to progressive disability. MS relapses are bouts of neurological symptoms such as numbness, weakness, imbalance and visual loss that can last days to months.
The first generation of self-injected medications reduced relapses by about one-third and as much as 80% of new brain disease seen on MRI (magnetic resonance imaging) scans. These medications fight the immune attack on the brain and spinal cord without compromising the body’s ability to fight infections. Tysabri (natalizumab), an infusion therapy given in the vein monthly, dropped relapses by 68% compared to placebo in clinical trial and has been available for treatment for over a decade.
Over the past 7 years, an array of new oral and antibody treatments for MS have become available that have unique effects on the immune system to block MS. Oral therapies are Aubagio, Gilenya and Tecfidera and new monoclonal antibody therapies are Lemtrada, Ocrevus, and Zinbryta. Some oral therapies have been shown to reduce relapses by more than half compared to placebo. Gilenya and Zinbryta demonstrated a superior reduction in relapses compared to Avonex. The advantages of good disease control must be balanced against serious risks of these drugs even if some risks are uncommon or rare.
Lemtrada (alemtuzumab) is a highly effective antibody therapy that in clinical trials has reduced relapses by half compared to Rebif. On Lemtrada, 43% of patients actually had less disability confirmed at end of 6 years compared to the onset of the study. Another antibody treatment, Ocrevus (ocrelizumab), also showed in clinical trials to reduced relapses almost in half and reduced contrast MRI activity by 95% compared to Rebif. Lemtrada transiently depletes T and B cells and Ocrevus consistently depletes B cells with potential serious risks including serious infusion reactions and serious infections.
One common approach to treating multiple sclerosis is starting with a self-injected medication with two decades of long-term safety information. These medications including Copaxone (glatiramer acetate) and interferons (including Avonex, Betaseron, Extavia and Rebif )have been effective for many patients without immune compromise. If new relapses, worsening disability or unchecked MRI activity occur, the first medication could be switched to another agent. The strategy is often referred to as “escalation” of treatment. This approach may be the safest option, but waiting too long to switch therapies may result in irreversible disability.
Another strategy is to seize the moment. People living with MS without new relapses and without new MRI activity have the best chance of preventing disability progression. One goal of MS treatment is achieving NEDA (No Evidence of Disease Activity) which means a patient is free of relapses, disability progression and MRI activity. Choosing a high-powered medication first to minimize risk of worsening disability to maximize quality of life is another treatment approach. Early in MS there can be changes such as nerve injury that may lead to irreversible disability. This earlier treatment approach tackles the disease aggressively from the start. Accepting potential long-term risks of these immune therapies with a lifelong disease is one concern. In addition, the use of some of these immune treatments might restrict the next treatment option. Not all therapies are indicated for first-line therapy in the United States.
Likely the best approach is a combination. This strategy involves stratifying the risk of disease, then matching with an appropriate medication. Some risk factors that increase risk for disability include being male, MS onset after age 40, incomplete recovery from first attack, frequent relapses the first 2 years of disease, spinal cord disease and higher amount of MS changes on initial MRI. Patients with lower risk of disability progression may choose a more conservative medication option. In contrast, someone at higher risk for disability may be willing to accept more risk for more effective treatment. It is critical for individuals living with MS to share their willingness to accept or not accept certain risks to control their disease. Neurologists also vary in their willingness to use higher risk medications which often influences the decision process. Each person living with MS should meet with their neurologist to clarify their individual risk of disability based on their disease.
Research advancements have led to a growing array of new MS therapies. To determine the best individualized treatment plan, being informed and open with healthcare providers is essential.
Mar 28 2017 Ocrevus (ocrelizumab) Approved!
The FDA has approved Ocrevus tonight for primary progressive and relapsing forms of multiple sclerosis. The approval is a major breakthrough since no treatments have previously been approved for primary progressive multiple sclerosis. This monoclonal antibody treatment works by depleted B cells, a type of immune cell. Ocrevus is given intravenously with half given the first day and a second half given 2 weeks later, followed by a single infusion every 6 months.
In 2 relapsing multiple sclerosis trials (OPERA I and II), patients treated with Ocrevus had 46 to 47% less relapses than Rebif. In addition, patients treated with Ocrevus were 40% less likely to progress in disability compared to Rebif treated patients. On MRI scans, the average number of active contrast-enhancing lesions were 94-95% less with Ocrevus treatment than Rebif. In a primary progressive trial (ORATORIO) of 732 patients, treatment with Ocrevus reduced risk of disability progression by 24% compared to placebo treatment. A 29% benefit was also seen on the time to walk 25 feet.
The most common side effects in clinical trials were infusion reactions and upper respiratory tract infections, which were mostly mild to moderate in severity. Although PML (progressive multifocal leukoencephalopathy) did not occur in Ocrevus clinical trials, this brain infection, which is potentially fatal, has occurred rarely with another B-cell depleting treatment. Other serious infections including reactivation of a Hepatitis B infection are risks. A higher rate of malignancies was seen on ocrelizumab than placebo or Rebif so possible risk of treatment with Ocrevus.
Dr. Singer discusses great progress in multiple sclerosis including on progressive disease and preventing brain size loss.
Zinbryta is an antibody therapy that binds onto a receptor (interleukin-2) on the surface of T immune cells. The SELECT trial studied 621 relapsing-remitting multiple sclerosis patients randomized to placebo and Zinbryta 150 mg [daclizumab high-yield process (HYP)] injected under skin every 4 weeks for 1 year. Relapses were reduced 54% for patients on Zinbryta compared to placebo. Zinbryta treatment was associated with 57% less disability progression compared to placebo.
In the DECIDE study of 1841 relapsing-remitting multiple sclerosis patients, Zinbryta under skin every 4 weeks was directly compared to Avonex weekly injections into muscle over 96 to 144 weeks of treatment. Patients on Zinbryta had 45% less relapses than Avonex. Less MRI activity was seen in people treated with Zinbryta (54% reduction on new or newly enlarging T2 lesions and 60% reduction on contrast-enhancing lesions).
Zinbryta can cause severe liver injury including liver failure and autoimmune hepatitis. Liver blood tests are required monthly and up to 6 months after last dose. Other immune-mediated disorders can occur including skin reactions, enlarge lymph nodes, and colon inflammation (colitis). These conditions may require treatment with steroids or immunosuppressive medication.
Most common side effects from Zinbryta (compared to Avonex) included upper respiratory infections, rash (37% of patients) and enlarged lymph nodes. Before starting Zinbryta, testing should be performed for viral hepatitis B and C as well as tuberculosis. Because of its safety profile, Zinbryta should generally be reserved for patients who have had inadequate response to 2 or more MS treatments.
Multiple sclerosis genetically clusters with other autoimmune diseases, especially Crohn’s and Celiac diseases. Genetic research shows that T regulatory cells and B cells (both types of a white blood cells called lymphocytes) are important in multiple sclerosis. High salt diet may cause immune dysregulation, leading to increased inflammation.
Remyelination (recoating the nerves with myelin) was a focus of a great 4 hour afternoon session. Approximately 5% of the cells in the brain are immature cells called OPCs (oligodendrocyte precursor cells) that potentially could make myelin. These cells may be important for learning and not just remyelination. Why does remyelination fail in MS? May be due to factors that block remyelination, damage to the nerve (axon section) itself, and the timing of repair.
To test compounds for myelin repair, remyelination can actually be visualized in translucent Zebra fish. Micropillars of immature myelin-making cells is another interesting approach to screen for effective compounds to increase new myelin production. The technique involves upside down cones coated with OPCs. Clemastine and benzatropine compounds worked in this model. To see if remyelination works in humans, imaging techniques being examined include PET with MRI scans, myelin water imaging and magnetic transference ratio analyses.
More data was presented on high efficacy treatments. In the OPERA trials of ocrelizumab (Orevus), 48% of patients had no evidence of disease activity (called NEDA) over 2 years in comparison to 25-29% of Rebif patients. NEDA means no relapses, no change in disability and no new MRI activity. Alemtuzumab (Lemtrada) was shown to very effective over 5 years in highly active MS patients whether previously treated with MS treatments or new to MS treatment.