Carrie M. Hersh

Background: There is growing support for high-efficacy disease-modifying therapy (DMT) in multiple sclerosis (MS), but escalation (ESC) approaches remain common. Objective: To describe decision-making in a pragmatic trial of early high-efficacy treatment (EHT) versus ESC. Methods: DELIVER-MS is a multi-center, pragmatic, randomized controlled trial (RCT) with a parallel observational study (OBS), which enrolled treatment-naïve people with RRMS in 31 UK/US sites. Primary outcome was as follows: 36-month brain volume loss according to initial treatment approach (EHT vs. ESC). Stepwise multivariable logistic regression was used to predict participation in RCT versus OBS and choice of EHT versus ESC within the OBS cohort. Results: In total, 816 people with MS were enrolled. Participants declined randomization due to preference for a particular DMT (85%), efficacy concerns (20%), and safety concerns (9%). RCT versus OBS participation was associated with lower relapse rate ( p = 0.043) and greater brain parenchymal fraction ( p = 0.002). Among 374 in the OBS cohort, 125 (33%) chose ESC and 249 (67%) chose EHT. People commencing EHT had higher education attainment ( p < 0.001) and relapse rate ( p = 0.025). Conclusion: Baseline DELIVER-MS data demonstrate that participants with milder disease are more likely to participate in RCT. The choice of EHT versus ESC was associated with demographic factors and disease activity. Clinical trial registration: NCT03535298

Background: Upper extremity impairment is a common disabling consequence of multiple sclerosis (MS). Little is known about factors influencing upper extremity functioning in MS. Objective: Identify associations with longitudinal changes in upper extremity performance. Methods: Using a real-world, retrospective cohort study (4140 persons with MS and 14,544 observations), multivariable repeated-measures analyses were completed for nine-hole peg test (9HPT) dominant and non-dominant hand times and their difference (asymmetry), with clinical, demographic, and social determinants as covariates. Interactions with time (disease duration) were examined. Results: Cross-sectionally, dominant, and non-dominant hand times were strongly correlated ( ρ = 0.78), and moderately correlated with asymmetry, walking speeds, and depressive symptoms. Longitudinally, older age, males, Hispanics, Blacks, ever smokers, public insurance beneficiaries, greater lower-limb impairment, progressive disease, and greater depressive symptoms were independently associated with worsening dominant and non-dominant times. Public insurance beneficiaries, greater lower-limb impairment, progressive disease, and greater depressive symptoms were associated with greater asymmetry. Males accrued dominant hand dysfunction more rapidly and had greater asymmetry than females over time, while those with increasing lower-limb impairment more rapidly experienced asymmetry over time. Discussion: These findings identify high-risk groups and inform future research to guide strategies for preserving upper extremity function in multiple sclerosis.

Aim: This study compares the efficacy of diroximel fumarate (DRF) with ocrelizumab (OCR) and interferon beta-1a (IFNβ-1a) for treating relapsing multiple sclerosis (MS) through matching-adjusted indirect comparisons (MAICs). Materials & methods: We used individual patient data from the EVOLVE-MS-1 (NCT02634307) study, the phase III trial of DRF (n = 1057), and group-level data from the OPERA I/II studies (NCT01247324 and NCT01412333), the 96-week, randomized, double-blind, phase III trials of OCR (n = 827) and IFNβ-1a (n = 829). EVOLVE-MS-1 data were adjusted to match the inclusion/exclusion criteria and baseline characteristics of OPERA I/II participants. Comparisons were made for annualized relapse rates (ARRs), confirmed disability progression (CDP) and radiological outcomes. Results: Baseline characteristics were balanced post-adjustment. ARR comparisons at 96 weeks showed no significant difference for DRF versus OCR (0.18 vs 0.16, p = 0.347) but favored DRF over IFNβ-1a (0.19 vs 0.29, p = 0.002). At 96 weeks, there were no significant differences in rates of 12-week or 24-week CDP between DRF and OCR (12 week: 6.4 vs 9.1%, p = 0.074; 24 week: 4.8 vs 6.9%, p = 0.14); both CDP outcomes favored DRF over IFNβ-1a (12 week: 6.5 vs 13.6%, p < 0.0001; 24 week: 4.9 vs 10.5%, p < 0.0001). The proportion of patients with gadolinium-enhancing lesions was higher for DRF versus OCR (16.4 vs 9.1%, p < 0.0001) but lower for DRF versus IFNβ-1a (15.7 vs 33.2%, p < 0.0001). The proportion of patients with new/newly enlarging T2 lesions was higher for DRF versus OCR (59.5 vs 38.7%, p < 0.0001), but there was no significant difference for DRF versus IFNβ-1a (58.4 vs 61.7%). Conclusion: While there were no significant differences in clinical outcomes (ARR, 12-week CDP and 24-week CDP) observed for DRF versus OCR, radiological outcomes indicated favorability for OCR. All outcomes favored DRF over IFNβ-1a, except from new/newly enlarging T2 lesions, which showed no significant difference.

The peak prevalence of multiple sclerosis (MS) is shifting to older patients. Using real-world data, we describe outcomes among older (≥60 years) and younger patients treated with interferon beta-1a or no disease-modifying therapy (no-DMT). Assessments over 24 months included annualized relapse rates (ARRs), patient-reported disability outcomes, and MS Performance Test (MSPT) outcomes. The study included 767 interferon-treated and 2783 no-DMT patients. ARR over 24 months was lower for the older and younger interferon-treated patients than the no-DMT patients. Mean change in Patient-Determined Disease Steps (PDDS) from baseline-24 months was -0.13 (1.08) in older interferon-treated patients vs 0.20 (1.30) in older no-DMT patients. Over 24 months ARR remained low and disability progression was stable for interferon-treated patients aged ≥ 60 years.

To describe the 12-month effectiveness, persistence, tolerability, and safety of ofatumumab (OMB), a highly effective disease-modifying therapy (DMT) for relapsing multiple sclerosis (MS), in a real-world MS population. Electronic medical records of patients starting OMB from October 2020 to August 2022 at two comprehensive MS centers were reviewed. Demographics and disease characteristics and 6- and 12-month clinical, patient-reported, and radiologic outcome measures were analyzed. A total of 175 patients started OMB with mean age 44.9 (SD 10.4) and disease duration 13.6 (SD 9.6) years. The cohort was 74% female, included 81% White and 13% Black American patients, and consisted of 80% relapsing-remitting MS or clinically isolated syndrome. Most (87%) had prior DMT exposure with 38% switching from high efficacy DMT. Over 12 months, 9.7% discontinued OMB (mean 117 days, SD 99.2), with tolerability issues being the most common reason. Thirty-nine (22%) had relapses in the year before starting OMB. By 12 months, only 1 relapse had occurred after approximately 4 months post-treatment initiation. This real-world study demonstrated that OMB is highly effective with robust persistence and good safety and tolerability by 12-month follow-up. Further analyses are planned to examine longer-term outcomes.

Background: Little is known about how multiple sclerosis (MS) presents in Hispanic/Latinx (HL) people with MS (pwMS). Objective: Compare age at onset (AAO) and onset severity between HL versus non-Hispanic White (NHW) pwMS. Methods: A cross-sectional study leveraged the MS PATHS registry spanning seven US tertiary care institutions. HL was subcategorized as HL White (HLW) and HL Other (HLO; all other races). Multivariable models examined relationships between ethnoracial variables and AAO and self-reported presenting disease course. Models were repeated restricting to those born ⩾1970. Results: The study population included 8231 pwMS, including 540 HL (200 HLW, 340 HLO). The sex distribution did not differ across ethnoracial subgroups. From the statistical models (1) HLO pwMS had an earlier AAO and a higher prevalence of initial progressive disease course than NHW pwMS; (2) among all HL pwMS, irrespective of race, AAO did not differ by sex or between relapsing and progressive MS at onset. In younger HLO adults (born ⩾1970), those with progressive MS at onset had an earlier AAO than those with relapsing MS; and (3) in HL pwMS there was no sex-bias in presenting disease course. Discussion: Distinct differences in the presentation of MS in HL compared with NHW individuals were observed.