dmt g pday_oct12
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A Talk to our local Cwm Taf national enhanced service provider GPs on their MS updateTRANSCRIPT
Disease Modifying Treatments:
Mediocrity and then some?
Dr Trevor Pickersgill
Consultant Neurologist
University Hospital of Wales
Royal Glamorgan Hospital
Hon Lecturer, Cardiff University
“Disease?”
Advice Explanation Expertise Support Signposting Now ‘rationers’ ‘prescribers’
“Modifying”
Theoretical model: treat early and aggressively
Treatmentat diagnosis Intervention
at diagnosis
Time
Disease Onset
Dis
abili
ty
Patients with a sustained (6 months) Expanded Disability Status Scale increase during the first 3 years of treatment.
La Mantia L et al. J Neurol Neurosurg Psychiatry doi:10.1136/jnnp-2012-303291
©2012 by BMJ Publishing Group Ltd
“Treatment?”
K Harding et al ENS 2012
‘mild’ drugs?
The Pipeline
Teva/Serono
BIOGEN
Really…..?
Pts with >1 exacerbation
Pts with 2yr progression
The IFNB Multiple Sclerosis Study The IFNB Multiple Sclerosis Study Group. 1993 Neurology. 43: 655-Group. 1993 Neurology. 43: 655-661661Jacobs LD et al. 1996 Annals of Jacobs LD et al. 1996 Annals of Neurology. 39: 285-294Neurology. 39: 285-294The PRISMS Study Group. 1998 The PRISMS Study Group. 1998 Lancet. 352: 1498-1504Lancet. 352: 1498-1504Jacobs LD et al. 2000 New Jacobs LD et al. 2000 New England Journal of Med England Journal of Med Medicine. 343: 898-904Medicine. 343: 898-904European Study Group on European Study Group on Interferon-1b in Secondary Interferon-1b in Secondary Progressive MS. 1998 Lancet. Progressive MS. 1998 Lancet. 352: 1491-1497352: 1491-1497Comi G et al. 2001 Lancet. 357: Comi G et al. 2001 Lancet. 357: 1576-15821576-1582
The New Dawn:monoclonals
Alemtuzumab Natalizumab Daclizumab Ocrelizumab Rituximab
Immune attack on the central nervous system and the mechanism of action of anti-VLA4 and anti-CD52.
Gold R , Hohlfeld R Pract Neurol 2006;6:248-251
©2006 by BMJ Publishing Grop Ltd
Natalizumab/Tysabri
Monthly IVI £13K ‘twice’ as effective injectable DMT Reserved for ‘HARRMS’ (NICE) I.e. 2+attacks in 1 yr with active MRI
(significant increase in lesions or Gd+) 25+ UHW. PML......
MOA of Natalizumab
1. Leukocyte migration from blood to tissue
3. Modulation of leukocyte apoptosis
2. Leukocyte priming and activation
Cannella B et al. Ann Neurol. 1995;37:424-435. TYSABRI SmPC; Yednock TA et al. Nature. 1992;356:63-66
TYSABRI Efficacy Summary
68%
54%
reduction in relapse rate vs placebo over 2 years (p < 0.001)
reduction in the risk of EDSS progression, sustained for 24 weeks, as assessed over 2 years (p < 0.001)
28%of patients free from all of the following measures of disease activity: relapses, Gd+ lesions, T1 weighted hypointense and T2 weighted hyperintense lesions and disability progression at 2 years 2
TYSABRI SmPC; Polman CH, et al. NEJM 2006; 354(9): 899-910; 2. TY00-004, Data on file. Biogen Idec Ltd
ITT Population
Annualized Relapse Rate
Placebo n=315 Natalizumab n=627
68%reduction
70%reduction
66%reduction
0.0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1.0
An
nu
aliz
ed R
elap
se R
ate
(95%
CI)
P<0.001
0.73
0.23
Years 0-2
P<0.001
P<0.001
0.81
0.67
0.260.20
Year 0-1 Year 1-2
Polman CH, et al. N Engl J Med. 2006;354:899-910; Polman C, et al. Presented at the 57th Annual Meeting of the American Academy of Neurology; April 12, 2005; Miami, FL
Kaplan–Meier Plots of the Time to Sustained Progression of Disability among Patients Receiving Natalizumab, as Compared with Placebo.
Polman CH et al. N Engl J Med 2006;354:899-910.
Another magic bullet?
Alemtuzumab Anti CD52 Cell lysis Lymphocyte depleter Annual infusions x2 Cheap..... .....but withdrawn autoimmunity
0
0.5
1
1.5
2
2.5
0 4 8 12 16 20 24
Haematological Effects of CAMPATH-1H
Time post Campath Infusion (Hours) 95% reduction within 1hr. Unaffected by steroids
Lym
ph
ocy
tes
(x10
9 /l)
0
1
2
3
4
1 10 100 1000
Days post CAMPATH-1HL
ymp
ho
cyte
s (x
109 /
l)
Normal Range
Moreau, T., A. Coles, et al. (1996). Moreau, T., A. Coles, et al. (1996). BrainBrain 119 (Pt 1)119 (Pt 1): 225-37: 225-37
Lymphocyte recovery after Alemtuzumab
Cossburn et al Neurology 2012(in press)
Campath rash
Cumulative number of relapses over time
P <0.0001
72%87%
RiskReduction
Annualized Relapse Rate (95% C.I.)
Interferon-beta 1a0.35 (0.27, 0.44)
Alemtuzumab Low-Dose
0.11 (0.07, 0.16)
Alemtuzumab High-Dose
0.05 (0.03, 0.09)Coles et al. AAN 2007.
Relapse-free
78%
59%55% Risk Reductionp<0.0001
Follow-up Month
Pat
ien
ts w
ith
ou
t R
elap
se (
%) 100
85
75
65
500 3 6 9 12 15 18 21 24
187 175 156 137 127 118 116 109 101376 366 358 340 321 313 306 299 287
SC IFNB-1aAnti CD52 mAb
No. of Observations
95
80
70
60
90
55
CARE-MS I
Mean EDSS Score Over Time
-0.57 (-0.30, -0.83)
-0.72 (-0.46, -0.98) P<0.0001
Alemtuzumabv. IFNB1a
Error bars = S.E.
The downside......
30% thyroid
3% ITP
Goodpasture’s
Lymphoma
Others
Rituximab 1 small trial
Ocrelizumab ‘ritux-max’ CD20 Phase 2 n=220 6 montly infusion MRI
Daclizumab IL2recA chain CD25
The Oral Explosion....
Fingolimod
BG12/DMF
Teriflunomide “Aubagio”
Laquinimod
Cladribine
Ponesimod ??
CLADRIBINE
The ‘winner’ of the race to market CLARITY NEJM 2010 N=1326 Placebo v high v low dose 0.33 v 0.15 relapse rate 10 tumours (5 fibroids!) Withdrawn from market worldwide
Efficacy Outcome Measures Relating to Relapse and Progression of Disability during the 96-Week Study Period (Intention-to-Treat Population).
Giovannoni G et al. N Engl J Med 2010;362:416-426.
FINGOLIMOD
S1P receptor modulator TRANSFORMS v Avonex FREEDOMS v placebo EDSS 0-5.5 ARR=1 N=1200 82% completion -54% RR MRI and disability Oral once daily
FINGOLIMOD
First dose in hospital Cardiac SEs First dose brady 1/2 deg HB Opthalmological - mac oedema Skin - 11 cancers (4 pl) £20,000
Gilenya prevents lymphocyte exit from lymph nodes
Gilenya causes: Internalisation of
the S1P1 receptor Inhibition of
lymphocyte exit along the S1P gradient
CNS, central nervous system; S1P, sphingosine 1-phosphateModel based on Brinkmann V et al. J Biol Chem 2002; Matloubian M et al. Nature 2004; Brinkmann V. Br J Pharmacol 2009
Gilenya induces reversible retention of circulating lymphocytes in lymph nodes, reducing peripheral lymphocyte counts and their recirculation to the CNS
Annualized Relapse Rate at 12 Months and the Time to the First Relapse.
Cohen JA et al. N Engl J Med 2010;362:402-415.
0
0.1
0.2
0.3
0.4
Fingolimod significantly reduced annualized relapse rates versus IFNβ-1a IM and placebo
0
0.1
0.2
0.3
0.4
TRANSFORMS 1-year results1TRANSFORMS 1-year results1 FREEDOMS 2-year results2FREEDOMS 2-year results2
EDSS, Expanded Disability Status Scale; IM, intramuscular 1. Table 2 page 8 FDA Advisory Committee presentation (10 June 2010). 2. Cohen JA et al. N Engl J Med 2010;362:402–15.
p < 0.001 for fingolimod versus IFNβ-1a IM p < 0.001 for fingolimod versus placebo
IFNβ-1a IM(n = 431)
Fingolimod 0.5 mg(n = 429)
Placebo(n = 418)
Fingolimod 0.5 mg(n = 425)
0.33
0.16
0.40
0.18
Ann
ualiz
ed r
elap
se r
ate
Ann
ualiz
ed r
elap
se r
ate
Annualized Relapse Rate estimate and p value are calculated using negative binomial regression model adjusted for treatment group, country, number of relapses in previous 2 years and baseline EDSS score.
0.17 or 52% reduction
0.22 or 54% reduction
Data refers to study group broader than the CHMP licensed indication. Fingolimod is indicated in patients with highly active and rapidly evolving severe RRMS. A consistent treatment effect was demonstrated in the licensed highly active subgroups.”
TERIFLUNOMIDE Selective and reversible inhibitior DHODH dihydro-orotate
dehydrogensae Mitoch enzyme Inhibits proliferation B/T cells Approved FDA 2012 2 phase 3 trials TEMSO N=1088 ARR 31% SAD 30% (27-31%)
Annualized Relapse Rate and Sustained Disability
Progression.
TEMSOO'Connor P et al. N Engl J Med 2011;365:1293-1303.
TOWER
2nd phase 3 trial terif 1+relapse 1yr 2+ 2yrs 48wks n=1169 70% completed study ARR -22.3% -36.3% Free relapses 55.4% v
37.7% SAD 22/21% v 15.8%
Alopecia 13% TENERE: no superiority
Rebif TOPIC - CIS
Effective, well tolerated, more long term safety data needed
2M pt-yrs in RA
BG12
Anti inflamm antioxidative stress ?cytoprotective
DEFINE v pl /CONFIRM v pl v GLA Fox NEJM 2012
50% RR SAD 33% Decreased brain atrophy
BG-12/DMF Risk relapse 2yrs 43% New/enlarging T2 75% N=2307 120 v 240 v pl v GLA (n=360) At least 1 relapse 12m -83% Gd+ Flushing/GI SEs
Clinical Outcomes at 2 Years in the Intention-to-
Treat Population.
Fox RJ et al. N Engl J Med 2012;367:1087-1097.
LAQUNIMOD
ALLEGRO 23% RR 36% SAD BRAVO More pronounced effect on disability than
RR??
Clinical Outcomes and MRI Measures of Efficacy According to Study
Group.
ALLEGRO
Comi G et al. N Engl J Med 2012;366:1000-1009.
Treatment Map
CIS RRMS HARRMS
ABCR
NATFING
ALEM
NEW ORALS
Monoclonals
Acknowledgements
Slideshare - Prof G Giovannoni Helen Durham Centre: Dr Katharine Harding Dr Mark Cossburn Prof Neil Robertson Dr Sebastian Luppe Dr Claire Hurst