Background and Objective: Pregnancy in mothers with multiple sclerosis (MS) commonly results in significant changes in disease activity and changes in clinical care, including the discontinuation of disease modifying therapy (DMT). This study aimed at understanding the clinical and patient-reported outcomes (PROs) before, during and 1-year after delivery. Materials and Methods: A total of 30 pregnant mothers with MS were recruited as part of the study. Clinical (relapse activity and disability changes), PRO information and MRI outcomes were collected on four separate visits: one baseline visit—0–30 days post-delivery; and 3 follow-up visits at week 24, week 36 and week 52 from the baseline. PRO was assessed using a validated questionnaire called the Fatigue Scale for Motor and Cognitive Function (FSMC). The MRI scans were analyzed, and the count of new T2 lesions and/or contrast-enhancing lesions was determined. Results: The average time between delivery and the start of DMT was 142.5 days. Relapse activity before the pregnancy was numerically linked with the activity during the pregnancy, where up to 57.1% of the activity during pregnancy occurred in pwMS with previously active disease before conception (statistically trending with p = 0.073). The relapse activity after the pregnancy occurred twice as often in pwMS whose MS was clinically active before conception. All five pwMS who experienced a relapse prior to the pregnancy experienced worsening in their physical PRO domain. Conclusions: Pre-pregnancy activity is crucial in the screening of mothers with MS at risk for post-partum relapses, worsening of clinical disability and/or PRO measures. A post-partum MS period may benefit from the routine PRO utilization and screening for its worsening. The inflammatory activity during pregnancy was not associated with short-term disease progression.

Background: Impaired cognition and ambulation are common in multiple sclerosis (MS). Dalfampridine is the first Food and Drug Administration (FDA)–approved medication to treat impaired ambulation in MS. Dalfampridine may benefit patients with cognitive impairment, given its effects on saltatory conduction and the association between cognitive and motor function. Objective: To examine the effects of dalfampridine on cognition in MS. To determine if the anticipated improved cognition is grounded in dalfampridine’s effects on ambulation. Methods: Adults with MS were randomized to dalfampridine ( n = 45) or placebo ( n = 16) for 12 weeks. Cognition and motor function were assessed at baseline and end-point. Results: T25FW and 6-minute walk (6MW) performance improved at end-point in the treatment group but not in the placebo group ( p < 0.05). Our primary outcome, performance on the Symbol Digit Modalities Test, did not improve. About 30% ( n = 12) of the dalfampridine group demonstrated ⩾20% improved ambulation and were categorized “responders.” Among “responders”, Symbol Digit Modalities test performance did not improve. However, performance on the Paced Auditory Serial Addition Test improved among “responders” ( p < 0.05). Conclusion: Dalfampridine benefits timed ambulation but not cognition. Some improvement among ambulation “responders” is consistent with prior reports of cognition-motor coupling in MS ( ClinicalTrials.gov #: NCT02006160).

Objectives To compare two modes of natalizumab cessation interventions: immediate versus tapered down, as measured by serial MRI and the occurrence of relapses during a 12-month period.Background Weighing progressive multifocal encephalopathy risk associated with 24months of natalizumab therapy against the benefits of disease control, we initiated a natalizumab discontinuation study.Methods A phase IV, 12-month, single-blinded randomised (MRI) study. Fifty relapsing patients with multiple sclerosis (MS) who had been on natalizumab therapy 24months and were contemplating natalizumab discontinuation were enrolled. Participants were randomised to either the immediate discontinuation group (IDG) or the tapered group (TG). IDG discontinued natalizumab at once and initiated another disease modifying therapy (DMT) following the last natalizumab infusion, while the TG received two more natalizumab infusions, at 6 and 8weeks (14weeks from study entry) before initiating another DMT. Standardised MRI was performed at baseline, 6 and 12months from the last natalizumab infusion.Results A higher rate of relapses in the IDG (n=28) compared to the TG (n=8) over 12months from the last infusion (p=0.007) was observed, most relapses occurred within 3months of discontinuation (20 vs 7 relapses, p=0.012). The IDG showed a higher number of new T2 lesions within 6-12months of discontinuation (p=0.025), a higher mean absolute T2-LV change from 0 to 12months (1.1 vs 0.1mL, p=0.024) and a higher number of new T1-hypointense lesions over 0-12months (p=0.005) as well as from baseline to 6months (p=0.026) compared to the TG.Conclusions Natalizumab discontinuation therapy was associated with development of new disease activity. Our tapered protocol showed benefits, as patients in the TG experienced less relapses and lower accumulation of MRI lesions compared to those in the IDG.

Objectives: To compare two modes of natalizumab cessation interventions: immediate vs. taper-down, as measured by serial MRI and occurrence of relapses during a 12 months period in patients treated with natalizumab for at least 24 months. Background: Weighing PML risk associated with 蠅24 months of natalizumab therapy against the benefits of disease control and patient satisfaction, we initiated a natalizumab discontinuation study. Methods: Phase IV, 12-month, single-blinded (MRI) randomized study. Fifty relapsing MS patients who have been on natalizumab therapy 蠅 24 months, JC positive, were enrolled. Subjects were randomized to either immediate discontinuation group (IDG) or the tapered group (TG). IDG discontinued natalizumab at once and initiated another disease modifying therapy (DMT), while TG received 2 more natalizumab infusions, at 6 weeks and at 8 weeks (14 weeks from study entry) before another DMT initiation. Intravenous methylprednisolone was also allowed. MRI was performed at baseline, 6 and 12 months. Results: The two groups did not differ in gender, BMI, number of natalizumab infusions, prior use of immunosuppressant’s, relapses preceding natalizumab, or number of Gd-enhancing lesions at time of natalizumab initiation. A higher rate of relapses in IDG (n=28) compared to TG (n=8) over 12 months of follow-up (p=.0009) was seen, most relapses being within 3 months of discontinuation (20 vs. 7 relapses, p=.016). IDG showed higher number of new T2 lesions within 6-12 months of discontinuation (p=.021), higher mean absolute T2-LV change (1106.8 vs. 55.5 ml, p=.024) and higher number of new T1 lesions over 0-12 months (p=.016) and 6-12 months (p=.019) compared to TG. Conclusion: Natalizumab discontinuation therapy was associated with development of new disease activity. Our taper protocol appears beneficial as patients in taper group experienced less relapses and lower accumulation of MRI lesions compared to those in the immediate discontinuation group. Study supported by Biogen Idec Disclosure: Dr. Weinstock-Guttman has received personal compensation for activities with Biogen Idec, Teva Neuroscience, EMD Serono, Pfizer Inc., Novartis, Genzyme Corporation, Sanofi-Aventis Pharmaceuticals, Inc., Mylan, and Acorda Therapeutics. Dr. Weinstock-Guttma Dr. Hagemeier has nothing to disclose. Dr. Saini has nothing to disclose. Dr. Kavak has nothing to disclose. Dr. Patrick has nothing to disclose. Dr. Ramasamy has nothing to disclose. Dr. Muhammad has nothing to disclose. Dr. Carl has nothing to disclose. Dr. Hojnacki has received personal compensation for activities with EMD Serono, Biogen Idec, Genzyme, and Teva. Dr. Zivadinov has received personal compensation for activities with Teva Neuroscience, Biogen Idec, EMD Serono, Novartis, Claret Medical Inc., and Genzyme Corporation as a speaker and/or consultant.

Multiple sclerosis (MS) causes cognitive impairment including slowed processing speed and problems with learning and memory. Stimulants are attractive candidates for improving mental speed but carry risk of addiction and other adverse behavioral effects. Lisdexamfetamine dimesylate (LDX) is a D-amphetamine prodrug currently approved for attention deficit (hyperactivity) disorder with the potential to be better tolerated due to its prolonged clinical effect. This phase II placebo-controlled, double-blind study aimed to assess the safety and efficacy of LDX in cognitively impaired MS patients. Subjects were patients with clinically definite MS, aged 18-56 years, and impaired on either of two primary outcomes: the Symbol Digit Modalities Test (SDMT) or the Paced Auditory Serial Addition Test (PASAT). Both SDMT and PASAT are measures of cognitive processing speed. Of 174 MS patients screened, 63 were randomized to 30 mg of LDX or placebo in a 2:1 fashion; the dose was increased as tolerated to 70 mg over 4 weeks and then maintained for another 4 weeks. Secondary outcomes were the Brief Visuospatial Memory Test Revised (BVMTR), the California Verbal Learning Test 2nd edition (CVLT2), both measures of episodic memory, and the Behavioral Rating Inventory of Executive Function for adults (BRIEF-A), a self-report measure of executive function. Fatigue and depression were also evaluated. There was significant improvement in the SDMT score (+4.6 vs. +1.3) and CVLT2 score (+4.7 vs. -0.9) in the LDX group compared with the placebo group among the 49 completers. There was no change on the other outcomes. A high proportion of both LDX-treated and placebo-treated subjects reported adverse events (73.5 % vs. 68.4 %). However, there were no serious adverse events noted in the study. These preliminary data indicate that LDX has the potential to be an efficacious treatment for MS patients with cognitive impairment.

PURPOSE:To characterize gene expression in multiple sclerosis (MS) patients after the first dose and chronic dosing of 30 microg, once weekly, intramuscular interferon-beta1a (IFN-beta) and to delineate the pharmacogenomic differences between Good Responders and Partial Responders to IFN-beta therapy. METHODS:The treatment responses after the first IFN-beta dose and chronic IFN-beta dosing were assessed in 22 relapsing MS patients (17 females, 5 males; average age: 41.5+/-SD 10.4 years). Gene expression profiles in peripheral blood mononuclear cells were obtained prior to treatment and at 1, 2, 4, 8, 24, 48, 120, 168 h after the first IFN-beta dose and at 1, 6 and 12 months after chronic dosing with once-weekly 30 microg IFN-beta-1a intramuscularly. Repeated measures statistics with false discovery rate control were used. The functional characteristics, biological pathways and transcription factor sites were analyzed. RESULTS:Of the 1000 genes modulated following the first dose and upon chronic dosing of IFN-beta in MS patients, approximately 35% were up-regulated and 65% were down- regulated; the percentage of modulated genes in common was approximately 50%. The expression of the pharmacodynamic mRNA markers of IFN-beta effect showed differences in time profiles for the Good Responder and Partial Responders to IFN-beta therapy and the Jak-STAT, TNFRSF10B, IL6, TGFbeta, retinoic acid and CDC42 pathways were differentially modulated. The patients with side effects to therapy showed differences in the TGFbeta1, IFNG/STAT3 and TNF pathways. CONCLUSIONS:Gene expression is a valuable tool for understanding the molecular mechanisms of IFN-beta action in MS patients.

Purpose: To investigate the relationship between immune cell secretion of brain-derived neurotrophic factor (BDNF) with clinical and MRI variables in multiple sclerosis (MS) patients.Background: BDNF exerts beneficial effects on neuronal growth and repair and is secreted by both neurons and immune cells. Consequently, it may mediate the crosstalk between the immune system and CNS in autoimmune diseases such as MS.Methods: Fifty-two relapsing MS patients (41 females, age: 48.8 +/- 6.6 years, disease duration: 12.7 +/- 8.4 years) were enrolled. Clinical and MRI measurements (including, T I-, T2- and contrast-enhancing (CE) lesion volumes (LVs); normalized measures of whole brain, white matter (WM) and gray matter (GM) volumes; diffusion weighted imaging measure of mean whole brain (W13) parenchyma diffasivity and magnetization transfer ratio (MTR) measures were obtained.Results.- Immune cell BDNF secretion after anti-CD3 plus anti-CD28 stimulation was positively associated with increased CE-LV (p=0.026). The MTR of CE-LV and normal-appearing (NA) WM (NAWM) were negatively associated with immune cell BDNF secretion after anti-CD3 plus anti-CD28 stimulation. Immune cell BDNF secretion after anti-CD3 plus anti-CD28 was positively associated with higher WNI volume (p=0.027). Immune cell BDNF secretion after anti-CD3 plus anti-CD28 stimulation was decreased with increasing disease duration (p=0.031). The BDNF secretion was independent of the BDNF Val66Met (dBSNP ID: rs6265) SNP genotype.Conclusions: Immune cell BDNF secretion is associated with the sites of higher inflammatory activity as evidenced by CE lesions and may represent an important factor associated with the WM volume of patients with MS. (c) 2007 Elsevier B.V. All rights reserved.

PURPOSE:Multiple sclerosis (MS) patients have a high risk of low bone density. The purpose of this study was to examine the molecular mechanisms potentially capable of modulating bone homeostasis in response to interferon-beta-1a (IFN-beta-1a) treatment and the focus was the bone-modulating system comprised of receptor activator of nuclear factor-kappaB (RANK), its ligand RANKL and its decoy receptor, osteoprotegerin (OPG).METHODS:In this open-label pharmacodynamic study, peripheral blood was obtained from relapsing-remitting MS patients just prior to and at multiple time points after intramuscular injection of 30 microg IFN-beta-1a. Samples were analysed for RANKL, tumour necrosis factor related apoptosis-inducing ligand (TRAIL), OPG and macrophage inflammatory protein-1 alpha/beta expression. Osteoclast precursor differentiation from peripheral blood cells of MS patients in the presence of exogenously added IFN-beta-1a was also assessed. Additionally, the changes in plasma levels of osteocalcin and the C-telopeptides after 1 year of treatment were measured as surrogate markers of bone formation and degradation, respectively.RESULTS:IFN-beta-1a treatment modulated RANKL and OPG in a selective, time-dependent manner. The levels of OPG protein decreased 25% at the 8-h time point, then increased 43% at the 24-h time point. The levels of free RANKL reached a maximum at the 8-h time point. Increases in the levels of macrophage inflammatory protein-1beta (MIP-1beta), a chemokine that increases osteolysis, were observed. The levels of the bone formation marker, osteocalcin, were lower in MS patients compared to controls and increased after one year of treatment. Ex vivo treatment of peripheral blood lymphocytes with IFN-beta resulted in a marked reduction of osteoclast-like cells in the presence of RANKL and macrophage colony stimulating factor.CONCLUSIONS:IFN-beta treatment induces complex, specific and time-dependent changes in multiple proteins and mRNAs related to bone homeostasis in MS patients.

Context: Osteoporosis and the increased fracture risk associated with osteoporosis become apparent in men approximately 10 years later than women. However, in recent studies, approximately 20% of healthy men in the age range 55 - 64 years were found to be osteopenic. Emerging data suggest a significantly increased prevalence of osteoporosis in men and women with multiple sclerosis ( MS) compared to age-matched controls, but no specific clinical testing recommendations are available for men. Objective: To determine the proportion of male MS patients with osteoporosis and to identify the factors associated with the reduction in bone mass. Design: Consecutive male MS patients seen at our MS clinic were screened with dual-X-ray absorptiometry ( DEXA) scan for determining the bone mineral density (BMD). All patients had neurological Expanded Disability Status Scale (EDSS) evaluation. The results were compared to healthy age-matched male reference population using the Z score and to a cohort of women MS patients and women controls. Calcium, to tal testosterone, sex-hormone binding globulin ( SHBG), 25-hydroxy-vitamin-D, and parathyroid hormone (PTH) were evaluated in male patients with decreased BMD. Relevant data on body mass index ( BMI), medication, alcohol consumption, smoking, and sexual dysfunction were recorded. Setting: Academic MS C entre. Patients and other participants: Forty consecutive male MS patients, age mean 51.2 +/- 8.7 years, and mean EDSS of 5.8 +/- 1.9 were evaluated with DEXA scan. Of these, 17.5% patients were relapsing - remitting (RR) MS, 57.5% were secondary progressive (SP) MS and 25% were primary progressive ( PP) MS. Main outcome measure: Proportion of male MS patients with reduced BMD at the lumbar spine and femoral neck. Results: Thirty-two (80%) of our patients had a reduced bone mass of either lumbar spine or the femoral neck; of these 17 patients (42.5%) had osteopenia and 15 patients (37.5%) had osteoporosis. Twenty-one per cent ( eight out of 38 patients) had vertebral, rib or extremities fractures. Multivariate linear regression analysis indicated that the EDSS (P < 0.0001) and BMI ( P = 0.0004) were the important factors associated with low BMD at the femoral neck and the EDSS was the important factor ( P = 0.0017) associated with low BMD at the lumbar spine. The same factors emerged as significantly associated with the corresponding Z scores, which are corrected for age and sex. No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis. Low levels of 25-hydroxy-vitamin-D were seen in 37.5% of patients. Conclusions: The proportion of male MS patients with reduced bone mass is high and disproportionate to their age and ambulation, consistent with an association between the MS disease pro cess and pathological bone loss. Increased awareness and bone density screening of male and female MS patients over 40 years of age is warranted.

The purpose of this report was to characterize the dynamics of the gene expression cascades induced by an IFN--1a treatment regimen in multiple sclerosis patients and to examine the molecular mechanisms potentially capable of causing heterogeneity in response to therapy. In this open-label pharmacodynamic study design, peripheral blood was obtained from eight relapsing- remitting multiple sclerosis patients just before and at 1, 2, 4, 8, 24, 48, 120, and 168 h after i.m. injection of 30 g of IFN--1a. The total RNA was isolated from monocyte-depleted PBL and analyzed using cDNA microarrays containing probes for >4000 known genes. IFN--1a treatment resulted in selective, time-dependent effects on multiple genes. The mRNAs for genes implicated in the anti-viral response, e.g., double-stranded RNA-dependent protein kinase, myxovirus resistance proteins 1 and 2, and guanylate binding proteins 1 and 2 were rapidly induced within 1- 4 h of IFN- treatment. The mRNAs for several genes involved in IFN- signaling, such as IFN-/ receptor-2 and Stat1, were also increased. The mRNAs for lymphocyte activation markers, such as IFN-induced transmembrane protein 1 (9 -27), IFN-induced transmembrane protein 2 (1- 8D), 2-microglobulin, and CD69, were also increased in a time-dependent manner. The findings demonstrate that IFN- treatment induces specific and time-dependent changes in multiple mRNAs in lymphocytes of multiple sclerosis patients that could provide a framework for rapid monitoring of the response to therapy. The Journal of Immunology, 2003, 171: 2694 -2702. eral double-blind, placebo-controlled, multicenter trials (1-3). Treatment with recombinant IFN--1a has been shown to slow the accumulation of physical disability in MS, reduce the fre- quency of relapses, and decrease the accumulation of disease bur- den and atrophy as evaluated by magnetic resonance imaging. IFN- was also shown to delay the conversion to clinically definite MS in patients with a first demyelinating event (4, 5). The effects of IFN- treatment are complex, and its pharmaco- dynamics at the genomic level in humans are poorly understood. In MS patients in particular, the benefit associated with IFN- ther- apy is difficult to monitor (6, 7), and despite extensive examination of the effects of IFN- in vitro with techniques such as flow cy- tometry, ELISA, RT-PCR, and proliferation and adhesion assays, the cellular, molecular, and immune mechanisms mediating the clinical effects of IFN- in MS are poorly delineated. Patients with relapsing MS respond better to IFN- treatment than patients with progressive disease. However, relapsing MS patients also exhibit considerable interindividual heterogeneity in their clinical re- sponses to IFN- therapy. Large phase III studies indicate a 30 - 40% general clinical benefit, although the response varied among patients. Magnetic resonance imaging data also underscore the het- erogeneity of responses to IFN- therapy in MS patients; 40% of patients show complete suppression of new gadolinium-enhancing lesions, whereas 20% of patients have 70% suppression (8). The goal of this study was to characterize the dynamics of the gene expression cascades induced by an IFN--1a treatment reg- imen in MS patients and to examine the molecular mechanisms potentially capable of causing heterogeneity in response to ther- apy. Our results demonstrate that the IFN--1a treatment causes large-scale, time-dependent changes in immunomodulatory gene expression in circulating lymphocytes that can be effectively as- sessed using the array technique. The gene expression changes are orchestrated with immunological changes at the protein and cel- lular levels.