Use of natalizumab in persons with multiple sclerosis: 2022 update.

BACKGROUND: Natalizumab is a humanized monoclonal antibody used for treatment of highly active relapsing-remitting multiple sclerosis (MS). With more than 15 years of post-marketing experience with natalizumab in Canada, several real-world studies have shown the long-term efficacy and safety of natalizumab. In addition, risk stratification/mitigation strategies for progressive leukoencephalopathy (PML), an adverse effect associated with natalizumab based on the John Cunningham virus (JCV) index; treatment duration beyond 24 months; and prior exposure to immunosuppressant drugs have been developed. METHODS: A group of neurologists from various MS clinics across Canada met in September 2021 to update the 2015 Canadian practice recommendations for the use of natalizumab in persons with MS (PwMS). RESULTS: The recommendations focused on the long-term efficacy and safety data from real-world studies, patient selection according to JCV index criteria, risk management strategies for PML (including extended interval dosing), and options for switching to currently available disease-modifying therapies for MS. CONCLUSIONS: The recommendations of clinical neurologists seek to optimize the management of PwMS who may benefit from treatment with natalizumab.

Lymphocytic colitis in the setting of teriflunomide use for relapsing multiple sclerosis.

Teriflunomide is an oral monotherapy used to treat relapsing multiple sclerosis. Although teriflunomide may be associated with gastrointestinal symptoms, these events are mild and self-limiting. We present a 39-year-old female who developed severe diarrhea and lost 20 pounds within 3 weeks of starting teriflunomide. Despite discontinuing teriflunomide and undergoing cholestyramine washout, her symptoms persisted. Celiac disease on genetic testing was positive, but no anti-transglutaminase and anti-endomysial antibodies were detected. She underwent colonoscopy and biopsy was consistent with lymphocytic colitis. Remission was achieved within days of starting budenoside. Our case describes a rare, but serious, gastrointestinal adverse event of teriflunomide.

Predictors of vocational status among persons with multiple sclerosis.

BACKGROUND: Multiple Sclerosis (MS) is a common cause of neurological disability in young to middle-aged adults, resulting in physical, psychosocial, and cognitive impairments. Manifestation of these symptoms during crucial work-life years can greatly influence the ability of persons with (PwMS) to retain employment. It is unknown what factors are most important in leading to work disability, and if/how these different factors interact with each other and result in work disability. OBJECTIVE: To determine significant predictors of vocational status among PwMS using a structural equation modeling approach. METHODS: A retrospective chart review identified PwMS at an academic tertiary care hospital. The following data was collected: demographics and disease characteristics, vocational status, physical disability status (Expanded Disability Status Scale, EDSS), fine motor function (Nine Hole Peg Test, NHPT), generalized fatigue (Fatigue Severity Scale, FSS), mood and anxiety symptoms (Hospital Anxiety and Depression Scale, HADS) and cognitive function (Symbol Digit Modalities Test, SDMT). An exploratory structural equation model (SEM) was developed to examine the predictive utility of clinical and psychosocial variables on vocational status after controlling for demographic and disease characteristics. The fit of the model to the data was examined using the comparative fit index (CFI), normal fit index (NFI), root-mean-squared error of approximation (RMSEA), and standardized root mean residual (SRMR). RESULTS: There were 158 PwMS included in the analysis. The final model demonstrated that SDMT (ß = 0.16), EDSS (ß = -0.33), and HADS-D (ß = -0.23) significantly predicted vocational status (ps < 0.05). It explained 37% of the variance and provided a good fit to the data (χ2(11) = 13.01, p > 0.05, SRMR = 0.055, RMSEA = 0.034, NFI = 0.94, CFI = 0.99. CONCLUSIONS: Physical disability, depressive symptoms, and reduced information processing affect work-related disability and vocational status among PwMS. Interventions targeting these factors should be prioritized by clinicians.

Joint Healthcare Professional and Patient Development of Communication Tools to Improve the Standard of MS Care.

INTRODUCTION: Effective communication between patients and healthcare professionals (HCPs) is important to enhance outcomes in multiple sclerosis (MS). However, in practice, patients often report a disconnect in communication. Communication tools to aid patient-HCP communication have a long history of use in many chronic conditions. For example, symptom diaries have been shown to enhance outcomes in cancer, headache and sleep disorder management. MS in the 21st Century, a Steering Group of HCP specialists and patients with MS (PwMS), has created two communication tools designed for use by both patients and their HCPs. METHODS: The Steering Group first identified prominent issues in patient-HCP communication through group discussions and survey data. Following this, a series of workshops led to the development of two communication tools as potential solutions to these identified issues in communication. RESULTS: The two most prominent issues identified were HCP time constraints during appointments and the misalignment of patient and HCP priorities-the communication tools developed through the workshops were created to address these. The "myMS priorities" tool [see supplementary materials] is designed to maximize the use of consultation time while the "myMS commitments" tool [see supplementary materials] aims to improve patient-HCP shared decision-making. CONCLUSIONS: The MS in the 21st Century Steering Group adopted a broad, iterative and collaborative approach in the development of these tools to help ensure they would be as useful as possible to both HCPs and PwMS. These tools have been developed through shared patient-HCP expertise and are based on existing tools in other therapy areas as well as a review of the existing literature and data from MS in the 21st Century Steering Group surveys. The next steps will focus on the validation of these tools through testing them in real-world environments and clinical trials. FUNDING: Merck KGaA, Darmstadt, Germany.

Comparing depression screening tools in persons with multiple sclerosis (MS).

OBJECTIVE: Depression is more common among persons with multiple sclerosis (MS) than the general population. Depression in MS is associated with reduced quality of life, transition to unemployment, and cognitive impairment. Two proposed screening measures for depression in MS populations are the Hospital Anxiety and Depression Scale (HADS) and the Beck Depression Inventory-Fast Screen (BDI-FS). Our objective was to compared the associations of the BDI-FS and the HADS-D scores with history of depressive symptoms, fatigue, and functional outcomes to determine the differential clinical utility of these screening measures among persons with MS. METHOD: We reviewed charts of 133 persons with MS for demographic information; scores on the HADS, BDI-FS, a fatigue measure, and a processing speed measure; and employment status. RESULTS: Structural equation modeling results indicated the HADS-D predicted employment status, disability status, and processing speed more effectively than did the BDI-FS, whereas both measures predicted fatigue. CONCLUSIONS: This study suggests the HADS-D is more effective than the BDI-FS in predicting functional outcomes known to be associated with depression among persons with MS. (PsycINFO Database Record

The Canadian survey of health, lifestyle and ageing with multiple sclerosis: methodology and initial results.

OBJECTIVE: People with multiple sclerosis (MS) are living longer so strategies to enhance long-term health are garnering more interest. We aimed to create a profile of ageing with MS in Canada by recruiting 1250 (5% of the Canadian population above 55 years with MS) participants and focusing data collection on health and lifestyle factors, disability, participation and quality of life to determine factors associated with healthy ageing. DESIGN: National multicentre postal survey. SETTING: Recruitment from Canadian MS clinics, MS Society of Canada chapters and newspaper advertisements. PARTICIPANTS: People aged 55 years or older with MS symptoms more than 20 years. OUTCOME MEASURES: Validated outcome measures and custom-designed questions examining MS disease characteristics, living situation, disability, comorbid conditions, fatigue, health behaviours, mental health, social support, impact of MS and others. RESULTS: Of the 921 surveys, 743 were returned (80.7% response rate). Participants (mean age 64.6±6.2 years) reported living with MS symptoms for an average of 32.9±9.5 years and 28.6% were either wheelchair users or bedridden. There was only 5.4% missing data and 709 respondents provided optional qualitative information. According to data derived from the 2012 Canadian Community Health Survey of Canadians above 55 years of age, older people with MS from this survey sample are about eight times less likely to be employed full-time. Older people with MS were less likely to engage in regular physical activity (26.7%) compared with typical older Canadians (45.2%). However, they were more likely to abstain from alcohol and smoking. CONCLUSIONS: Despite barriers to participation, we were able to recruit and gather detailed responses (with good data quality) from a large proportion of older Canadians with MS. The data suggest that this sample of older people with MS is less likely to be employed, are less active and more disabled than other older Canadians.