Clinical factors predicting better outcome of acute multiple sclerosis relapses

[lady_express_44]

Clinical factors predicting better outcome of acute multiple sclerosis relapses

A. Achiron, I. Sarova-Pinhas, D. Magalashvili, M. Dolev, H. Raz, J. Chapman (Tel Aviv, IL)

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Background: Prediction of the clinical outcome of an acute multiple sclerosis (MS) relapse is of importance, particularly in light of the considerable risk for disability even in patients treated with modifying immunomodulating treatments. The aim of the present study was to evaluate clinical outcome of acute severe relapses and identify clinical factors associated with better clinical outcome.

Methods: Clinical and demographic variables were analyzed in relapsing-remitting MS patients that experienced an acute severe relapse. All patients had an increase in neurological disability of at least 2 points by the Expanded Disability Status Scale (EDSS) and were treated with 1g/day intravenous methylprednisolone for 5 consecutive days. Clinical outcome was assessed at 1 and 4 months after relapse onset. The cumulative probability to improve was calculated according to the Cox proportional hazards model with various covariates (age, gender, disease duration, EDSS score change during relapse, EDSS functional score changes and immunomodulatory treatment).

Results: 376 relapsing remitting MS patients (mean age 32.1 years, disease duration 9.4 years) that experienced acute MS relapses were evaluated. 78.45% (295/376) were treated with immunomodulatory drugs. EDSS assessed up to 90 days before the onset of the acute relapse increased from a mean of 2.2 to 4.6. At 1 and 4 months post-relapse evaluations, 39.6% and 60.4% of patients improved respectively. Logistic regression using hierarchical model demonstrated that better clinical outcome was most influenced by immunomodulatory treatment and lower EDSS score change during the relapse, followed by lower scores in cerebellar, urinary and pyramidal functional scales. Age, disease duration and duration of immunomodulatory treatment did not affect relapse outcome.

Conclusion: Predictive factors associated with better clinical outcome of severe acute MS relapse are mainly related to lesser disease activity in treated patients.

http://registration.akm.ch/einsicht.php?XNABSTRACT_ID=50710&XNSPRACHE_ID=2&XNKONGRESS_ID=63&XNMASKEN_ID=900

Cherie

[lady_express_44]

Early prognostic value of relapses with multifocal presentation in multiple sclerosis

M. Debouverie, S. Pittion-Vouyovitch, S. Louis, J-C. Lacour, H. Vespignani (Nancy, F)

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Introduction: To identify predictive clinical factors of disability in multiple sclerosis (MS) patients, particular attention should be paid to early occurring relapses with multifocal presentation. Recently, in a large trial enrolling patients after the first manifestation suggestive of a demyelinating disease, the authors proposed labeling patients as monofocal or multifocal and that clinical characteristic was interpreted as an early predictor and as a variable of interest for the initiation of disease-modifying treatment (Benefit study). The objective of the current study was to determine the influence of the number of relapses in separate clinical areas on the rate of progression of irreversible disability in patients with MS.

Methods: 1,004 MS patients from Department of Neurology of Nancy, France, were analyzed. The relationships between baseline demographic, clinical predictors and the time to the assignment of EDSS scores of 3, 4, and 6 were assessed using a Cox regression model.

Results: For relapsing-remitting (RR) patients, a shorter time to the assignment of an irreversible EDSS score of 4 was associated with a relapse in separate areas. When the first two attacks were in separate areas or in the same area, the median time from the onset of MS to the assignment of a score of 4 was 10.0 (95% CI = 8.4 to 11.9) and 17.9 years (95% CI = 14.0 to 24.5) respectively (p<0.0001). Median times were not influenced by gender or the time between the first two relapses.

When the first three attacks (n=676) were with monofocal presentation, or with two multifocal presentations, or with three multifocal presentations, the median times from the onset of MS to the assignment of a score of 4 were 8.8 years (95% CI = 7.8 to 10.2), 14.2 years (95% CI = 11.9 to 21.0) and 19.6 (95% CI = 14.9 to 31.1), respectively (p<0.0001). Multivariate analysis for the time of the assignment of an EDSS score of 4 confirmed that the following factors were important: age at onset of MS, recovery from the first relapse; and occurrence of relapses with multifocal presentation. The median times were not influenced by gender or the time between the first two relapses.

Conclusions: Among the RR patients, a relapse in separate areas was identified as a new clinical predictor.

http://registration.akm.ch/einsicht.php?XNABSTRACT_ID=51783&XNSPRACHE_ID=2&XNKONGRESS_ID=63&XNMASKEN_ID=900

Cherie

[fahrmar]

I am of the multi-focal group. Boo!

[lawnerd]

Logistic regression using hierarchical model demonstrated that better clinical outcome was most influenced by immunomodulatory treatment and[/COLOR][/COLOR] lower EDSS score change during the relapse, followed by lower scores in cerebellar, urinary and pyramidal functional scales. Age, disease duration and duration of immunomodulatory treatment did not affect relapse outcome.

Conclusion: Predictive factors associated with better clinical outcome of severe acute MS relapse are mainly related to lesser disease activity in treated patients.

Cherie,
I am confused by the 2 portions of this text I have underlined. If one of the 2 things better clinical outcome was most influenced by is Immunomodulatory tx. And, indeed that factor was seen as important enough to list it first in that sentence, why is it not mentioned in the "conclusion"?

I guess where I am trying to go, is does the result of this study say one should use immunomodualtory tx or not? how does this relate to all the studies which got CRAB's approved by the FDA in the first place? I thought all the CRABs are beleived to lessen disease progression and disability over time. Otherwise, boy are we being had???

Thx for any insight you sharper minds have to offer.

[Harpist]

I am of the multi-focal group. Boo!

Hi fahrmar,

Multifocal is good. If I read this right, multifocal groups accumulate disability more slowly.

Being multifocal myself, I'm going with that interpretation *grin*.

Good Roads

Harpist

[Harpist]

Cherie,
I am confused by the 2 portions of this text I have underlined. If one of the 2 things better clinical outcome was most influenced by is Immunomodulatory tx. And, indeed that factor was seen as important enough to list it first in that sentence, why is it not mentioned in the "conclusion"?

I guess where I am trying to go, is does the result of this study say one should use immunomodualtory tx or not? how does this relate to all the studies which got CRAB's approved by the FDA in the first place? I thought all the CRABs are beleived to lessen disease progression and disability over time. Otherwise, boy are we being had???



Hi lawnerd,

The immunomodualtory therapy they were talking about here was IV steroids, not ABCRs.

Why was this mentioned in the results and not the conclusions? My best guess is - because this was probably was observational data and not a controlled trial - there was a strong correlation between disease activity prior to relapse and the use of IV steroids. As a result, it cannot be reported that BOTH affect the results. If this is the case, they would select the one with the strongest correlation and drop the other.

But that is a SWAG (scientific wild-a$$ guess).

Good Roads

Harpist

[lady_express_44]

Hi lawnerd,

The immunomodualtory therapy they were talking about here was IV steroids, not ABCRs.



Yeah, that's what I thought, at first. But when I went to quote the article, I noticed:

All patients had an increase in neurological disability of at least 2 points by the Expanded Disability Status Scale (EDSS) and were treated with 1g/day intravenous methylprednisolone for 5 consecutive days.

Then it goes on to say:

78.45% (295/376) were treated with immunomodulatory drugs.

If they were "ALL treated with methylprednisolone, 1g/day", the 78.45% must refer to "other" immunomodulatory drugs, i.e. CRABs ... :confused:

I concluded that the critical factor in this study was that lesser disease activity during the attack, is the predictor of better recovery. The use of immunomodulatory drugs (CRABs) seems to have contributed to less activity, but less activity was the key.

Just my interpretation.

Cherie

[Harpist]

Cherie,

You are probably right about the use of ABCRs in this study. I missed the comment about all patients getting IV steroids. Interesting that 78% of the patients were on ABCRs - they must have been a part of the recruitment. I look forward to seeing the entire study in the future. Too many studies coming out right now to keep up (that is a good thing *grin*).

It will be interesting too see the details of the study. Logistic regression using hierarchical model is a particularly nasty analysis. Unlike the analysis used for blinded trial data, there is no "correct" answer (it is the same for all regression models with interrelated input data).

Good Roads

Harpist

[fahrmar]

Hi fahrmar,

Multifocal is good. If I read this right, multifocal groups accumulate disability more slowly.

Being multifocal myself, I'm going with that interpretation *grin*.

Good Roads

Harpist

Thank you, Harpist! I studied graduate level research and statistics for two years (2001-03, social sciences), but find that with my brain fog, I have to read studies very slowly, or I miss too many important details, like multi-focal is GOOD! I LIKE your interpretation, it works for me! ;)

Peace to you.