Polypharmacy and multiple sclerosis: A population-based study.

BACKGROUND: Little is known about polypharmacy and multiple sclerosis (MS). OBJECTIVES: To estimate polypharmacy prevalence in a population-based MS cohort and compare persons with/without polypharmacy. METHODS: Using administrative and pharmacy data from Canada, we estimated polypharmacy prevalence (⩾5 concurrent medications for >30 consecutive days) in MS individuals in 2017. We compared the characteristics of persons with/without polypharmacy and described the number of polypharmacy days, the most common medication classes contributing to polypharmacy and hyper-polypharmacy prevalence (⩾10 medications). RESULTS: Of 14,227 included individuals (75% women), mean age = 55.4 (standard deviation (SD): 13.2) years; 28% (n = 3995) met criteria for polypharmacy (median polypharmacy days = 273 (interquartile range (IQR): 120-345)). Odds of polypharmacy were higher for women (adjusted odds ratio (aOR) = 1.14; 95% confidence intervals (CI):1.04-1.25), older individuals (aORs 50-64 years = 2.04; 95% CI:1.84-2.26; ⩾65 years = 3.26; 95% CI: 2.92-3.63 vs. <50 years), those with more comorbidities (e.g. ⩾3 vs. none, aOR = 6.03; 95% CI: 5.05-7.22) and lower socioeconomic status (SES) (e.g. most (SES-Q1) vs. least deprived (SES-Q5) aOR = 1.64; 95% CI: 1.44-1.86). Medication classes most commonly contributing to polypharmacy were as follows: antidepressants (66% of polypharmacy days), antiepileptics (47%), and peptic ulcer drugs (41%). Antidepressants were most frequently co-prescribed with antiepileptics (34% of polypharmacy days) and peptic ulcer drugs (27%). Five percent of persons (716/14,227) experienced hyper-polypharmacy. CONCLUSION: More than one in four MS persons met criteria for polypharmacy. The odds of polypharmacy were higher for women, older persons, and those with more comorbidities, but lower SES.

Low socioeconomic status was associated with a higher mortality risk in multiple sclerosis.

BACKGROUND: The relationship between socioeconomic status (SES) and mortality among persons with multiple sclerosis (PwMS) is poorly understood. OBJECTIVE: To investigate the association between SES and mortality risk in PwMS. METHODS: From health-administrative data, we identified 12,126 incident MS cases with a first demyelinating event (MS 'onset') occurring between 1994 and 2017. Cox proportional hazard model assessed the association between socioeconomic status quintiles (SES-Qs) at MS onset and all-cause mortality. RESULTS: Lower SES-Qs were associated with higher mortality risk; adjusted hazard ratios: SES-Q1 (most deprived) =1.61 (95% confidence interval (CI) = 1.36-1.91); SES-Q2 = 1.26 (95% CI = 1.05-1.50); SES-Q3 = 1.22 (95% CI = 1.02-1.46); SES-Q4 = 1.13 (95% CI = 0.94-1.35) versus SES-Q5 (least deprived). CONCLUSION: A lower SES was associated with higher mortality risk in PwMS.

Central nervous system macrophages in progressive multiple sclerosis: relationship to neurodegeneration and therapeutics.

There are over 15 disease-modifying drugs that have been approved over the last 20 years for the treatment of relapsing-remitting multiple sclerosis (MS), but there are limited treatment options available for progressive MS. The development of new drugs for the treatment of progressive MS remains challenging as the pathophysiology of progressive MS is poorly understood.The progressive phase of MS is dominated by neurodegeneration and a heightened innate immune response with trapped immune cells behind a closed blood-brain barrier in the central nervous system. Here we review microglia and border-associated macrophages, which include perivascular, meningeal, and choroid plexus macrophages, during the progressive phase of MS. These cells are vital and are largely the basis to define lesion types in MS. We will review the evidence that reactive microglia and macrophages upregulate pro-inflammatory genes and downregulate homeostatic genes, that may promote neurodegeneration in progressive MS. We will also review the factors that regulate microglia and macrophage function during progressive MS, as well as potential toxic functions of these cells. Disease-modifying drugs that solely target microglia and macrophage in progressive MS are lacking. The recent treatment successes for progressive MS include include B-cell depletion therapies and sphingosine-1-phosphate receptor modulators. We will describe several therapies being evaluated as a potential treatment option for progressive MS, such as immunomodulatory therapies that can target myeloid cells or as a potential neuroprotective agent.

Emergency department use by persons with MS: A population-based descriptive study with a focus on infection-related visits.

We described emergency department (ED) visits (all visits and infection-related) by persons with multiple sclerosis (MS) in British Columbia, Canada (1 April 2012 to 31 December 2017). We identified 15,350 MS cases using health administrative data; 73.4% were women, averaging 51.4 years at study entry. Over 4.9 years of follow-up (mean), 56.0% of MS cases visited an ED (mean = 0.6 visits/person/year; total = 37,072 visits). A diagnosis was documented for 25,698 (69.3%) ED visits, and 18.4% (4725/25,698) were infection-related. Inpatient admissions were reported for 20.4% (5238/25,698) of all and 29.2% (1380/4725) of infection-related ED visits. Findings suggest that the ED plays a substantial role in MS healthcare and infection management.

Disease-modifying drugs for multiple sclerosis and subsequent health service use.

OBJECTIVE: We assessed the relationship between the multiple sclerosis (MS) disease-modifying drugs (DMDs) and healthcare use. METHODS: Persons with MS (aged ⩾18 years) were identified using linked population-based health administrative data in four Canadian provinces and were followed from the most recent of their first MS/demyelinating event or 1 January 1996 until the earliest of death, emigration, or study end (31 December 2017 or 31 March 2018). Prescription records captured DMD exposure, examined as any DMD, then by generation (first-generation (the injectables) or second-generation (orals/infusions)) and individual DMD. The associations with subsequent all-cause hospitalizations and physician visits were examined using proportional means model and negative binomial regression. RESULTS: Of 35,894 MS cases (72% female), mean follow-up was 12.0 years, with person-years of DMD exposure for any, or any first- or second-generation DMD being 63,290, 54,605 and 8685, respectively. Any DMD or any first-generation DMD exposure (versus non-exposure) was associated with a 24% lower hazard of hospitalization (adjusted hazard ratio, aHR: 0.76; 95% confidence intervals (CIs): 0.71-0.82), rising to 29% for the second-generation DMDs (aHR: 0.71; 95% CI: 0.58-0.88). This ranged from 18% for teriflunomide (aHR: 0.82; 95% CI: 0.67-1.00) to 44% for fingolimod (aHR: 0.56; 95% CI: 0.36-0.87). In contrast, DMD exposure was generally not associated with substantial differences in physician visits. CONCLUSION: Findings provide real-world evidence of a beneficial relationship between DMD exposure and hospitalizations.

Adherence to laboratory monitoring among people taking oral drugs for multiple sclerosis: A Canadian population-based study.

OBJECTIVE: To examine laboratory testing adherence by persons initiating an oral disease-modifying therapy (DMT) for multiple sclerosis (MS). METHODS: Population-based health administrative and laboratory data were accessed in British Columbia, Canada, to identify everyone filling their first prescription for dimethyl fumarate (DMF), fingolimod or teriflunomide (2011-2015). The proportion of people adherent to each drug monograph's recommended laboratory monitoring schedule, pre- and on-DMT, was estimated. The association between patient characteristics and adherence was examined using multivariable logistic regression. RESULTS: A total of 1016 people were included (DMF 567, fingolimod 253 and teriflunomide 196). The proportions of people adherent to pre-DMT liver and lymphocyte tests ranged from 88% to 91% and 91% to 94%, respectively, while 77% adhered to pre-DMF urinalysis. Adherence to the first on-DMT liver test was 89% for DMF (within 6 months), 61% for fingolimod (within 3 months) and 40% for teriflunomide (within 1 month). Men were less likely than women to have pre-DMF urinalysis (adjusted odds ratio (aOR); 95% confidence interval (CI): 0.40-0.95) or on-DMF liver (aOR: 0.46; 95% CI: 0.23-0.95) or lymphocyte (aOR: 0.47; 95% CI: 0.22-0.98) tests. CONCLUSIONS: Adherence to recommended laboratory testing was high (>77%) before oral DMT initiation, but lower once on drug. There is a need to understand the long-term consequences of suboptimal laboratory monitoring and sex differences in the DMT-treated MS population.

Patterns of comorbidities in women with breast cancer: a Canadian population-based study.

PURPOSE: Improving the understanding of co-existing chronic diseases prior to and after the diagnosis of cancer may help to facilitate therapeutic decision making in clinical practice. This study aims to examine patterns of comorbidities in Canadian women with breast cancer. METHODS: We conducted a retrospective cohort study using provincial linked administrative health datasets from British Columbia, Canada, between 2000 and 2013. Women diagnosed with breast cancer between 2005 and 2009 were identified. The index date was defined as the date of diagnosis of breast cancer. Subsets of the breast cancer cohort were identified based on the absence of individual type of comorbidity of interest within 5 years prior to breast cancer diagnosis. For each subset, cases were then individually matched by year of birth at 1:2 ratios with controls without a history of cancer and the individual type of comorbidity of interest within 5 years prior to the assigned index year, matching with the year of breast cancer diagnosis of the corresponding case. Baseline comorbidities were measured over a 1-year period prior to the index date using two comorbidity indices, Rx-Risk-V and Aggregated Diagnosis Groups (ADG). Cox regression model was used to assess the development of seven specific comorbidities after the index date between women with breast cancer and non-cancer women. RESULTS: The most prevalent baseline comorbidity in the breast cancer cohort measured using the Rx-Risk-V model was cardiovascular conditions (39.0%), followed by pain/pain-inflammation (34.8%). The most prevalent category measured using the ADG model was major signs or symptoms (71.8%), followed by stable chronic medical conditions (52.2%). The risks of developing ischemic heart disease, heart failure, depression, diabetes, osteoporosis, and hypothyroidism were higher in women with breast cancer compared to women without cancer, with the hazard ratios ranging from 1.09 (95 CI% 1.03-1.16) for ischemic heart disease to 2.10 (95% CI 1.99-2.21) for osteoporosis in the model adjusted for baseline comorbidity measured using Rx-Risk-V score. CONCLUSION: Women with breast cancer had a higher risk of developing new comorbidities than women without cancer. Development of coordinated care models to manage multiple chronic diseases among breast cancer patients is warranted.

Comorbidities in Australian women with hormone-dependent breast cancer: a population-based analysis.

OBJECTIVE: To compare how frequently selected chronic diseases developed in women with breast cancer receiving endocrine therapy, and in women without cancer. DESIGN, SETTING AND PARTICIPANTS: Retrospective, rolling cohort study, analysing a random 10% sample of Pharmaceutical Benefits Scheme (PBS) data for the period 1 January 2003 - 31 December 2014. Women with breast cancer who first commenced endocrine therapy between January 2004 and December 2011 were identified, and age- and sex-matched (1:10) by comorbidity with control groups of women who did not have a dispensing record for antineoplastic agents during the study period or the comorbidity of interest at baseline. MAIN OUTCOME MEASURES: Development of any of eight pre-selected comorbidities, identified in PBS claims data with the RxRisk-V model. RESULTS: Women with hormone-dependent breast cancer were significantly more likely than women in the control group to develop depression (overall hazard ratio [HR], 1.36; 95% CI, 1.26-1.46), pain or pain-inflammation (HR, 1.30; 95% CI, 1.23-1.38), osteoporosis (overall HR, 1.27; 95% CI, 1.17-1.39), diabetes (HR, 1.24; 95% CI, 1.10-1.41), cardiovascular disorders (overall HR, 1.22; 95% CI, 1.13-1.32), and gastric acid disorders (HR, 1.20; 95% CI, 1.13-1.28). The hazard ratios for developing cardiovascular disorders, depression and osteoporosis were highest during the first year of endocrine therapy. The risk of hyperlipidaemia was lower among women with breast cancer than in the control group (HR, 0.88; 95% CI, 0.81-0.96). There was no significant difference between the two groups in the risk of reactive airway diseases (HR, 1.05; 95% CI, 0.98-1.13). CONCLUSION: Comorbid conditions are more likely to develop in women who have been diagnosed with hormone-dependent breast cancer than in women without cancer. Our results further support the need to develop appropriate models of care to manage the multiple chronic disorders of breast cancer survivors.

Pre-Frailty and Frailty in Hospitalized Older Adults: A Comparison Study in People with and without a History of Cancer in an Acute Medical Unit.

A prospective observational study was conducted in a cohort of older adults ≥65 years (n = 329), admitted to the acute medical unit (AMU) of a tertiary hospital, to describe and compare characteristics including frailty status and clinical outcomes. Multivariable models compared older adults with and without a history of cancer to determine characteristics associated with frailty and pre-frailty. An adjusted Poisson regression model was used to compare the length of hospital stay (LOS) between the two groups. About one-fifth (22%) of the cohort had a history of cancer. The most common cancer types were prostate (n = 20), breast (n = 13), lung (n = 8) and gastrointestinal (n = 8). There was no difference in the prevalence of pre-frailty/frailty among patients with or without a history of cancer (58% vs. 57%, p > 0.05). Pre-frailty/frailty was associated with polypharmacy (OR 8.26, 95% CI: 1.74 to 39.2) and malnutrition (OR 8.91, 95% CI: 2.15 to 36.9) in patients with a history of cancer. Adjusted analysis revealed that the risk of having a longer LOS was 24% higher in older adults with a history of cancer than those without (IRR 1.24, 95% CI 1.10 to 1.41, p < 0.001). Clinicians in the AMU should be aware that older adults with a history of cancer have a higher risk of a longer LOS compared to those without.

Disease-modifying drugs, multiple sclerosis and infection-related healthcare use in British Columbia, Canada: a population-based study.

Background: Much remains unknown surrounding the disease-modifying drugs (DMDs) used to treat multiple sclerosis and infection-related healthcare use in the 'real-world' setting. We examined if DMD exposure was associated with altered infection-related healthcare use. Methods: We assessed if DMD (versus no) exposure was associated with altered infection-related hospitalizations, physician claims, and prescriptions filled in British Columbia, Canada (1996-2017). Healthcare use was assessed using negative binomial and proportional means regression models, reported as sex-/age-/comorbidity-/calendar year-/socioeconomic-adjusted rate and hazard ratios [aRR, aHR], with 95% confidence intervals [CIs]). Findings: We identified 19,360 multiple sclerosis cases (13,940/19,360; 72.0% women; mean age at study start = 44.5 standard deviation, SD = 13.3; mean follow-up = 11.7 [SD = 7.3] years). Relative to unexposed periods, exposure to any DMD was associated with a lower infection-related rate of physician claims (aRR = 0.88; 95% CI:0.85-0.92) and hazard of hospitalization (aHR = 0.64; 95% CI:0.56-0.73), and a higher rate of infection-related prescriptions (aRR = 1.14; 95% CI:1.08-1.20). Exposure to any injectable or oral DMD was associated with a lower infection-related rate of physician claims (injectable aRR = 0.88; 95% CI:0.84-0.92, oral aRR = 0.83; 95% CI:0.77-0.90) and hazard of hospitalization (injectable aHR = 0.65; 95% CI:0.56-0.75, oral aHR = 0.54; 95% CI:0.38-0.77), whereas intravenous DMD exposure was not (aRR = 0.99; 95% CI:0.86-1.14, aHR = 0.73; 95% CI:0.49-1.09). Exposure to any injectable or intravenous DMD was associated with a higher rate of infection-related prescriptions (injectable aRR = 1.15; 95% CI:1.08-1.22, intravenous = 1.34; 95% CI:1.15-1.56), whereas oral DMDs were not (aRR = 0.98; 95% CI:0.91-1.05). Interpretation: DMD exposure for the treatment of MS was associated with differences in infection-related healthcare use. While infection-related hospitalizations and physician visits were lower, prescription fills were higher. How these differences in infection-related healthcare use affect outcomes in persons with multiple sclerosis warrants consideration. Funding: Canadian Institutes of Health Research (CIHR); German Research Foundation (DFG).

Cardiovascular mortality in people with cancer compared to the general population: A systematic review and meta-analysis.

BACKGROUND: Cardiovascular disease (CVD) is the leading cause of non-cancer death in cancer survivors, but the risk of CVD varies between cancers. OBJECTIVES: To synthesise available evidence on patterns and magnitude of CVD mortality risk. METHODS: A systematic search of Medline (OVID), CINAHL and Scopus databases from 01-January-2000 to 16-July-2023 of studies of people with cancer, reporting CVD mortality in cancer population compared with a reference population (e.g. general population) as standardised mortality ratios (SMR). Meta-analysis of SMRs across cancer and CVD types were pooled using a random-effects model to allow for heterogeneity of the true effect size across studies. RESULTS: We identified 136 studies from 16 countries. Sample sizes ranged from 157 to 7,529,481. The majority (n = 98; 72%) were conducted in the United States, followed by Europe (n = 22; 16%). The most common cancers studied were gastrointestinal (n = 34 studies), haematological (n = 31) and breast (n = 29). A total of 876 CVD SMRs were extracted across diverse CVD conditions. Of those, the majority (535; 61%) indicated an increased risk of CVD death (SMR >1), 109 (12%) a lower risk of CVD death (SMR <1) and 232 (27%) an equivalent risk (95% CI of SMR included 1) compared to the general population. The meta-analysis of all reported SMRs showed an increased risk of CVD death (SMR = 1.55, 95% CI = 1.40-1.72) in cancer survivors compared with the general population. The SMR varied between CVD conditions and ranged from 1.36 (95% CI = 1.29-1.44) for heart diseases to 1.56 (95% CI = 1.39-1.76) for cerebrovascular diseases. SMR varied across cancer types, ranging from 1.14 (95% CI = 1.04-1.25) for testicular/germ cell tumours to 2.82 (95% CI = 2.20-3.63) for brain/central nervous system tumours. CONCLUSIONS: Cancer survivors are at increased risk of premature CVD mortality compared to the general population, but the risk varies by cancer type and CVD. Future research should focus on understanding mechanisms behind the increased CVD risk to develop appropriate interventions.

Adverse Events Associated With Disease-Modifying Drugs for Multiple Sclerosis: A Multiregional Population-Based Study

BACKGROUND AND OBJECTIVES: It is not possible to fully establish the safety of a disease-modifying drug (DMD) for multiple sclerosis (MS) from randomized controlled trials as only very common adverse events occurring over the short-term can be captured, and the quality of reporting has been variable. We examined the relationship between the DMDs for MS and potential adverse events in a multiregion population-based study. METHODS: We identified people with MS using linked administrative health data from 4 Canadian provinces. MS cases were followed from the most recent of first MS or related demyelinating disease event on January 1, 1996, until the earliest of emigration, death, or December 31, 2017. DMD exposure primarily comprised ß-interferon, glatiramer acetate, natalizumab, fingolimod, dimethyl fumarate, teriflunomide, and alemtuzumab. We examined associations between DMD exposure and infection-related hospitalizations and physician visits using recurrent events proportional means models and between DMD exposure and 15 broad categories of incident adverse events using stratified multivariate Cox proportional hazard models. RESULTS: We identified 35,894 people with MS. While virtually all DMDs were associated with a 42%-61% lower risk of infection-related hospitalizations, there was a modest increase in infection-related physician visits by 10%-33% for select DMDs. For incident adverse events, most elevated risks involved a second-generation DMD, with alemtuzumab's hazard of thyroid disorders being 19.42 (95% CI 9.29-36.51), hypertension 4.96 (95% CI 1.78-13.84), and cardiovascular disease 3.72 (95% CI 2.12-6.53). Natalizumab's highest risk was for cardiovascular disease (adjusted hazard ratio [aHR] 1.61; 95% CI 1.24-2.10). For the oral DMDs, fingolimod was associated with higher hazards of cerebrovascular (aHR 2.04; 95% CI 1.27-3.30) and ischemic heart diseases (aHR 1.64; 95% CI 1.10-2.44) and hypertension (aHR 1.73; 95% CI 1.30-2.31); teriflunomide with higher hazards of thyroid disorders (aHR 2.30; 95% CI 1.11-4.74), chronic liver disease (aHR 1.94; 95% CI 1.19-3.18), hypertension (aHR 1.76; 95% CI 1.32-2.37), and hyperlipidemia (aHR 1.61; 95% CI 1.07-2.44); and from complementary analyses (in 1 province), dimethyl fumarate with acute liver injury (aHR 6.55; 95% CI 1.96-21.87). DISCUSSION: Our study provides an extensive safety profile of several different DMDs used to treat MS in the real-world setting. Our findings not only complement those observed in short-term clinical trials but also provide new insights that help inform the risk-benefit profile of the DMDs used to treat MS in clinical practice. The results of this study highlight the continued need for long-term, independent safety studies of the DMDs used to treat MS. CLASSIFICATION OF EVIDENCE: This study provides Class III evidence that for patients with MS, while DMD exposure reduces the risk of infection-related hospitalizations, there are increased risks of infection-related physician visits and incident adverse events for select DMDs.

Patterns of mental health service utilisation in people with cancer compared with people without cancer: analysis of the Australian National Study of Mental Health and Wellbeing.

PURPOSE: To compare the patterns of mental health service utilisation between people with and without cancer. METHODS: We performed a cross-sectional study using data of all respondents aged ≥ 25 years from the Australian National Study of Mental Health and Wellbeing 2020-2021 conducted during the COVID-19 pandemic. Comparisons were made between the two groups (cancer versus non-cancer) using logistic regression models. RESULTS: The study comprised 318 people with cancer (55% female) and 4628 people without cancer (54% female). Cancer survivors had a higher prevalence of reporting poor health (38% versus 16%) and mental distress (18% versus 14%) than people without cancer. There were no significant differences between people with and without cancer in the odds of consulting general practitioner, psychiatrist and other health professionals for mental health, although people with cancer were significantly more likely to consult a psychologist than people without cancer (adjusted odds ratio (aOR) = 1.64, 95%CI = 1.05-2.48). While the odds of being hospitalised for physical health was significantly higher in cancer survivors than people without cancer (aOR = 2.32, 95%CI = 1.78-3.01), there was only a negligible number of people reported being hospitalised for mental health between the two groups. Several factors were associated with higher odds of mental health service utilisation including younger age, unpartnered marital status and presence of a current mental condition. CONCLUSIONS: Alarmingly, despite experiencing higher prevalence of poor health status and mental distress, cancer survivors did not utilise more mental health services than the general population. That is, there is a higher degree of untreated, or undertreated, distress in cancer than in the general population. IMPLICATIONS FOR CANCER SURVIVORS: Further research to identify optimal approaches of mental health care delivery for cancer survivors are urgently needed.

Health status and mental distress in people with cancer and comorbid conditions: The Australian National Health Survey analysis.

INTRODUCTION: Data on the impact of specific comorbidities on health outcomes is limited. We compared health status and mental distress between individuals with and without cancer according to comorbidity type. METHODS: A cross-sectional analysis using data from the Australian National Health Survey 2017-18 including all respondents aged ≥25 years with and without a history of cancer. The odds of poor health and mental distress were reported according to cancer status, and specific individual and cluster of comorbidities. RESULTS: There were 1982 individuals (52% female) with cancer and 12,635 (51% female) without cancer. Individuals with cancer were older, and more likely to have a comorbidity compared with those without cancer. They were more likely to report poor health than those without cancer for each specific comorbidity; except for skin conditions and infectious diseases; with the adjusted odds ratio (aOR) ranging from 1.34 (95% CI = 1.01-1.79) for digestive disorders to 2.93 (95% CI = 1.62-5.29) for blood conditions. The strongest association with poor health (aOR 2.79, 95% CI = 2.27-3.43) and mental distress (aOR 9.01, 95% CI = 7.25-11.20) was observed for those with a comorbid mental illness. Exploratory cluster analysis identified four distinct comorbidity clusters: low comorbidity, musculoskeletal, respiratory and cardiometabolic; cancer survivors in the cardiometabolic cluster had a higher odds of reporting poor health (aOR 3.50, 95% CI = 2.48-4.92) and mental distress (aOR 2.33, 95% CI = 1.53-3.55) than those with a low comorbidity. CONCLUSIONS: Comorbidities in cancer survivors were common and associated with inferior health status, although the magnitude of the effect varied by comorbidity type. Risk assessment and management of comorbidities should be an important priority for cancer care and research.

Multiple sclerosis disease-modifying drug use by immigrants: a real-world study.

Little is known about disease-modifying drug (DMD) initiation by immigrants with multiple sclerosis (MS) in countries with universal health coverage. We assessed the association between immigration status and DMD use within 5-years after the first MS-related healthcare encounter. Using health administrative data, we identified MS cases in British Columbia (BC), Canada. The index date was the first MS-related healthcare encounter (MS/demyelinating disease-related diagnosis or DMD prescription filled), and ranged from 01/January/1996 to 31/December/2012. Those included were ≥ 18 years old, BC residents for ≥ 1-year pre- and ≥ 5-years post-index date. Persons becoming permanent residents 1985-2012 were defined as immigrants, all others were long-term residents. The association between immigration status and any DMD prescription filled within 5-years post-index date (with the latest study end date being 31/December/2017) was assessed using logistic regression, reported as adjusted odds ratios (aORs) with 95% confidence intervals (CIs). We identified 8762 MS cases (522 were immigrants). Among immigrants of lower SES, odds of filling any DMD prescription were reduced, whereas they did not differ between immigrants and long-term residents across SES quintiles (aOR 0.96; 95%CI 0.78-1.19). Overall use (odds) of a first DMD within 5 years after the first MS-related encounter was associated with immigration status.

Multiple sclerosis incidence: A systematic review of change over time by geographical region.

BACKGROUND: The incidence of multiple sclerosis (MS) has reportedly increased over time; however, change in MS incidence has not been rigorously assessed globally. METHODS: We followed the guidelines for the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement. Two independent reviewers systematically searched Scopus, PubMed and Web of Science for peer-reviewed publications in English from 1 January 1985 to 24 September 2020 reporting MS incidence for at least two contiguous five-year periods with clearly-defined case ascertainment. The outcome was change in MS incidence rate according to geographical region. RESULTS: We identified 64 papers providing 65 regional estimates (including three paediatric-onset MS) across 24 countries covering ∼3% of the world's population (in 2000/1 or closest available total population for the entire country), with quality (adapted Newcastle-Ottawa Scale) ranging from sufficient to good. Studies were mainly from Italy (n=14 including San Marino), Norway (n=10) or Canada (n=9), with no studies in the Africa or South-East Asia regions. Of the 62 whole-of-population estimates, MS incidence rates: significantly increased in 38 (61%), significantly decreased in 13 (21%) and remained stable in 11 (18%). In the paediatric-onset studies, MS incidence was stable in two (67%) and increased in one (33%). Many estimates derived from only selected (often small) regions of a country. For 42 (68%) of the whole-of-population estimates (and two of the paediatric-onset estimates) a consistent case definition or diagnostic criteria over the entire study period was explicitly reported. Across the n=9 whole-of-population estimates based on a consistent case definition for the duration of the study period, and including a substantial proportion of the population of a country (≥one-third), incidence rates were stable in n=3, increased in n=3 and decreased in n=3. Studies using a consistent case definition covered ∼2.7% of the global population; incidence rates were stable in 0.9% of the global population, decreased in studies covering 1%, and increased in those covering 0.8% of the global population. CONCLUSION: The studies reporting change in MS incidence rate over time were limited by world region and the proportion of the global population covered. Although by number of studies, the predominant pattern was increasing MS incidence, in studies where a consistent case definition was used across the duration of the study and with high population coverage, no predominant pattern of MS incidence was evident.

Disease-Modifying Drugs for Multiple Sclerosis and Association With Survival.

BACKGROUND AND OBJECTIVES: We examined the association between the disease-modifying drugs (DMDs) for multiple sclerosis (MS) and survival in a multiregion population-based study. METHODS: We accessed multiple administrative health databases from 4 Canadian provinces. Persons with MS were identified and followed from the most recent of the first MS or demyelinating event or January 1, 1996 (index date), until death, emigration, or December 31, 2017. Association between the first-generation and second-generation DMDs and all-cause mortality was examined using stratified Cox proportional hazard models, reported as adjusted hazard ratios (aHRs). Timing of DMD initiation was explored, with findings reported at 2, 5, or 10 years postindex date, representing very early, early, or late initiation. RESULTS: We identified 35,894 persons with MS; 72% were female. The mean age at index date was 44.5 years (SD = 13.6). The total person-years of follow-up while DMD-exposed was 89,180, and total person-years while unexposed was 342,217. Compared with no exposure, exposure to any DMD or to any first-generation DMD was associated with a 26% lower hazard of mortality (both aHRs 0.74; 95% CI 0.56-0.98), while any second-generation DMD exposure was associated with a 33% lower hazard (aHR 0.67; 95% CI 0.46-0.98). Earlier DMD initiation (beta-interferon or glatiramer acetate vs no exposure) was associated with a significant mortality effect (p < 0.05), while later initiation was not (95% CIs included 1). However, the survival advantage with earlier initiation diminished over time, no longer reaching statistical significance at 15 years postindex date. DISCUSSION: Our study demonstrates an association between the DMDs for MS and improved survival in the real-world setting.

Disease-Modifying Drug Uptake and Health Service Use in the Ageing MS Population.

Background: Evidence regarding the efficacy or effectiveness of the disease-modifying drugs (DMDs) in the older multiple sclerosis (MS) population is scarce. This has contributed to a lack of evidence-based treatment recommendations for the ageing MS population in practice guidelines. We examined the relationship between age (<55 and ≥55 years), DMD exposure and health service use in the MS population. Methods: We conducted a population-based observational study using linked administrative health data from British Columbia, Canada. We selected all persons with MS and followed from the most recent of their first MS or demyelinating event, 18th birthday or 01-January-1996 (index date) until the earliest of emigration, death or 31-December-2017 (study end). We assessed DMD exposure status over time, initially as any versus no DMD, then by generation (first or second) and finally by each individual DMD. Age-specific analyses were conducted with all-cause hospitalizations and number of physician visits assessed using proportional means model and negative binomial regression with generalized estimating equations. Results: We included 19,360 persons with MS (72% were women); 10,741/19,360 (56%) had ever reached their 55th birthday. Person-years of follow-up whilst aged <55 was 132,283, and 93,594 whilst aged ≥55. Any DMD, versus no DMD in the <55-year-olds was associated with a 23% lower hazard of hospitalization (adjusted hazard ratio, aHR0.77; 95%CI 0.72-0.82), but not in the ≥55-year-olds (aHR0.95; 95%CI 0.87-1.04). Similar patterns were observed for the first and second generation DMDs. Exposure to any (versus no) DMD was not associated with rates of physician visits in either age group (<55 years: adjusted rate ratio, aRR1.02; 95%CI 1.00-1.04 and ≥55 years: aRR1.00; 95%CI 0.96-1.03), but variation in aRR was observed across the individual DMDs. Conclusion: Our study showed beneficial effects of the DMDs used to treat MS on hospitalizations for those aged <55 at the time of exposure. In contrast, for individuals ≥55 years of age exposed to a DMD, the hazard of hospitalization was not significantly lowered. Our study contributes to the broader understanding of the potential benefits and risks of DMD use in the ageing MS population.

Women's Health in Multiple Sclerosis: A Scoping Review.

BACKGROUND: Women with multiple sclerosis (MS) may face challenges related to managing reproduction, pregnancy, and menopause while simultaneously managing their disease. The purpose of this scoping review was to map the literature broadly related to topics relevant to women's health in MS to inform the clinical and research communities about the existing types and sources of evidence and knowledge gaps. Apart from coverage of topics within the field of women's health, we were interested in potential gaps related to geographic and racial and ethnic diversity. We also aimed to understand the degree of inclusion of women with progressive MS in this research. METHODS: We searched the EMBASE and Ovid Medline databases from 1980 until November 23, 2020. We included case-control and cohort studies, clinical trials and case series published in any language, conducted in women with MS, clinically isolated syndrome, or radiologically isolated syndrome, that addressed women's health. Two reviewers independently screened abstracts and full-text reports for study inclusion, and completed data extraction. RESULTS: Of 112,106 citations screened, 1,041 underwent full-text review and 353 met the inclusion criteria. The number of studies regarding women's health has increased exponentially over time. Almost half of the studies were conducted (at least in part) in Europe, while 21.7% were conducted in North America; only one study was conducted in Africa. Most studies did not report the race or ethnicity of their participants (n = 308, 87.2%). Among the 353 studies, 509 topics were reported as some studies addressed more than one topic. Over one-third of these focused on pregnancy (n = 201, 37.2%), followed by fetal/neonatal outcomes (14.4%) and sexual dysfunction (10%). Among the 201 studies that focused on pregnancy, only 51 (25.4%) included participants with progressive MS. CONCLUSIONS: This review identifies important knowledge gaps related to women's health in MS and particularly the need for future studies to include participants with a broader range of races and ethnicities, with progressive MS, and living in Asia-Pacific and African regions.