POOR PROGNOSIS MAY REQUIRE DECISIVE ACTION

  • MS is the leading cause of nontraumatic young-adult neurologic disability1
  • Cumulative effects of disease activity incurred early in the disease course may lead to progressive disease and long-term neurologic damage2-4
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Consider independent factors to identify certain patients who may be at increased risk of a poor prognosis5 :

DEMOGRAPHICS
  • Older age at onset (≥40 years old)6-8
  • Race: African American, Hispanic9,10
  • Gender: Male8,9,11
  • Smoker12
CLINICAL
  • High relapse rate in the first 2 years9,11,13
  • Incomplete recovery after relapse9,11
  • Short interval between first and second relapse8,11,13
  • Motor involvement or ataxia in relapse9,11
  • Cognitive impairment13,14
  • Vascular risk factors (eg, diabetes)15
  • Multifocal CIS onset (suggestive of multiple neurologic areas affected by inflammation)5,13
PARACLINICAL
  • Brain stem and/or spinal cord lesions9
  • Presence of contrast-enhancing lesions9,11
  • High T2-lesion load9
  • Chronic T1-hypointense lesions11,16
  • Early brain atrophy11,16
  • Oligoclonal bands in the CSF (eg, IgG, IgM)11,17-19

Currently, there are no DMTs indicated to treat any clinical or paraclinical factors listed above. This includes TYSABRI.

Prompt decision making early in the course of relapsing MS and throughout treatment may affect patient outcomes2,20-22

THERE IS A STRONG CORRELATION BETWEEN MRI LESION LOAD AND THE SEVERITY OF PHYSICAL DISABILITY AT 5 YEARS23

Adapted from Comi, Clin Ther, 2009; Compston, Lancet, 2008; Fisniku, Brain, 2008; and Trapp, Neuroscientist, 1999.2,24-26
For illustrative purposes only.

There may be a therapeutic window of opportunity in optimizing treatment3,4,27,28

  • The volume and the accumulation of T2 lesions over 2 years were significantly correlated with future physical disability29
  • Brain lesions at baseline were predictive of physical disability status after 10 years30

MRI can help detect subclinical disease2,31,32,a

  • After 1 year of treatment31,32:
    • Relapse-free patients continued to show active disease on MRI and significant risk of worsening physical function
    • Risk of disease progression has been shown to rise as lesion load and relapse rate increase

Consider monitoring for an inadequate response after the first 6 to 12 months of therapy. An inadequate response can be defined by a combination of parameters, which may include31,33-35 :

MRI
ACTIVITY
  • Ongoing disease activity detected by MRI31,35
  • ≥1 Gd+ lesion or new or enlarging T2-hyperintense lesion within 1 year31,33
LEVEL OF PHYSICAL
DISABILITY
  • An increase in EDSS score on new therapy4,33
  • ≥1-point EDSS score increase at
    6 months36
RELAPSE
FREQUENCY
  • Recurring relapse after treatment initiation31,35
  • ≥1 relapse within 1 year4,31

Proportion of patients on first-line therapies with an inadequate response can vary based on criteria used. Some studies prior to 2010 show that up to two-thirds of patients may exhibit an inadequate response after relapsing MS treatment initiation.4,33,37

REAL EXPERIENCES TREATING RMS

Leading physicians discuss the need to monitor disease activity to help guide treatment decisions.

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CSF=cerebrospinal fluid; IgG=immunoglobulin G; IgM=immunoglobulin M; DMT=disease-modifying therapy; ARR=annualized relapse rate; EDSS=Expanded Disability Status Scale.

INDICATION

TYSABRI® (natalizumab) is indicated as monotherapy for the treatment of relapsing forms of multiple sclerosis, to include clinically isolated syndrome, relapsing-remitting disease, and active secondary progressive disease, in adults. TYSABRI increases the risk of PML. When initiating and continuing treatment with TYSABRI, physicians should consider whether the expected benefit of TYSABRI is sufficient to offset this risk.

IMPORTANT SAFETY INFORMATION

WARNING: Progressive Multifocal Leukoencephalopathy (PML)

TYSABRI® (natalizumab) increases the risk of PML, an opportunistic viral infection of the brain that usually leads to death or severe disability. Risk factors for the development of PML include the presence of anti-JCV antibodies, duration of therapy, and prior use of immunosuppressants. These factors should be considered in the context of expected benefit when initiating and continuing treatment with TYSABRI.

Healthcare professionals should monitor patients on TYSABRI for any new sign or symptom that may be suggestive of PML. TYSABRI dosing should be withheld immediately at the first sign or symptom suggestive of PML. For diagnosis, an evaluation including a gadolinium-enhanced MRI scan of the brain and, when indicated, cerebrospinal fluid analysis for JC viral DNA are recommended.

Because of the risk of PML, TYSABRI is available only through a restricted program under a Risk Evaluation and Mitigation Strategy (REMS) called the TOUCH® Prescribing Program.

  • Infection by the JC Virus (JCV) is required for the development of PML
  • There are no known interventions that can reliably prevent PML or that can adequately treat PML if it occurs
  • Postmarketing data suggest that the risk of developing PML may be associated with relative levels of serum anti-JCV antibody compared to a calibrator as measured by ELISA (often described as an anti-JCV antibody index value)
  • MRI findings may be apparent before clinical signs or symptoms suggestive of PML. Monitoring with MRI for signs that may be consistent with PML may be useful, and any suspicious findings should lead to further investigation to allow for an early diagnosis of PML, if present. Consider monitoring patients at high risk for PML more frequently. Lower PML-related mortality and morbidity have been reported following TYSABRI discontinuation in patients with PML who were initially asymptomatic compared to patients with PML who had characteristic clinical signs and symptoms at diagnosis
  • PML has been reported after discontinuation of TYSABRI in patients who did not have findings suggestive of PML at the time of discontinuation. Patients should continue to be monitored for any new signs or symptoms that may be suggestive of PML for at least 6 months after discontinuation of TYSABRI
  • Adverse events that may occur during plasma exchange (PLEX) include clearance of other medications and volume shifts, which have the potential to lead to hypotension or pulmonary edema. Although PLEX has not been prospectively studied in TYSABRI-treated patients with PML, it has been used in such patients in the postmarketing setting to remove TYSABRI more quickly from the circulation. There is no evidence that PLEX has any benefit in the treatment of opportunistic infections such as PML
  • JCV infection of granule cell neurons in the cerebellum, i.e., JCV granule cell neuronopathy (GCN), with symptoms similar to PML, has been reported in patients treated with TYSABRI. JCV GCN can occur with or without concomitant PML and can cause cerebellar dysfunction. Diagnosis and management of JCV GCN should follow guidance provided for PML
  • Immune reconstitution inflammatory syndrome (IRIS) has been reported in the majority of TYSABRI-treated patients who developed PML and subsequently discontinued TYSABRI. In almost all cases, IRIS occurred after PLEX was used to eliminate circulating TYSABRI. It presents as a clinical decline in the patient’s condition after TYSABRI removal (and, in some cases, after apparent clinical improvement) that may be rapid, can lead to serious neurological complications or death, and is often associated with characteristic changes in the MRI. TYSABRI has not been associated with IRIS in patients discontinuing treatment with TYSABRI for reasons unrelated to PML. In TYSABRI-treated patients with PML, IRIS has been reported within days to several weeks after PLEX. Monitoring for development of IRIS and appropriate treatment of the associated inflammation should be undertaken

Contraindications

  • TYSABRI is contraindicated in patients who have or have had PML
  • TYSABRI is contraindicated in patients who have had a hypersensitivity reaction to TYSABRI

TYSABRI TOUCH Prescribing Program

  • Because of the risk of PML, TYSABRI is available only through a restricted distribution program under a REMS called the TOUCH® Prescribing Program
  • Patients must be enrolled in the TOUCH Prescribing Program, read the Medication Guide, understand the risks associated with TYSABRI, and complete and sign the Patient-Prescriber Enrollment Form

Herpes Infections – Encephalitis, Meningitis and Acute Retinal Necrosis

  • TYSABRI increases the risk of developing encephalitis and meningitis caused by herpes simplex and varicella zoster viruses
  • Serious, life-threatening, and sometimes fatal cases have been reported in the postmarketing setting in multiple sclerosis patients receiving TYSABRI
  • The duration of treatment with TYSABRI prior to onset ranged from a few months to several years
  • Monitor patients receiving TYSABRI for signs and symptoms of meningitis and encephalitis. If herpes encephalitis or meningitis occurs, TYSABRI should be discontinued, and appropriate treatment for herpes encephalitis/meningitis should be administered
  • Patients being administered TYSABRI are at a higher risk of acute retinal necrosis (ARN), a fulminant viral infection of the retina caused by the family of herpes viruses. Patients with eye symptoms such as decreased visual acuity, redness or eye pain should be referred for retinal screening as serious cases of ARN can lead to blindness of one or both eyes
  • Following clinical diagnosis of ARN, consider discontinuation of TYSABRI

Hepatotoxicity

  • Clinically significant liver injury, including acute liver failure requiring transplant, has been reported in patients treated with TYSABRI in the postmarketing setting
  • Signs of liver injury, including markedly elevated serum hepatic enzymes and elevated total bilirubin, occurred as early as six days after the first dose; signs of liver injury have also been reported for the first time after multiple doses
  • TYSABRI should be discontinued in patients with jaundice or other evidence of significant liver injury (e.g., laboratory evidence)

Hypersensitivity/Antibody Formation

  • Hypersensitivity reactions have occurred in patients receiving TYSABRI, including serious systemic reactions (e.g., anaphylaxis) which occurred at an incidence of <1%
  • Reactions usually occur within 2 hours of the start of the infusion. Symptoms associated with these reactions can include urticaria, dizziness, fever, rash, rigors, pruritus, nausea, flushing, hypotension, dyspnea, and chest pain
  • If a hypersensitivity reaction occurs, discontinue administration of TYSABRI and initiate appropriate therapy. Patients who experience a hypersensitivity reaction should not be re-treated with TYSABRI
  • Hypersensitivity reactions were more frequent in patients with antibodies to TYSABRI compared with patients who did not develop antibodies to TYSABRI in both MS and CD studies
  • Patients who receive TYSABRI for a short exposure (1 to 2 infusions) followed by an extended period without treatment are at higher risk of developing anti-natalizumab antibodies and/or hypersensitivity reactions on re-exposure, compared to patients who received regularly scheduled treatment

Immunosuppression/Infections

  • The immune system effects of TYSABRI may increase the risk for infections
  • In Study MS1, certain types of infections—including pneumonias and urinary tract infections (including serious cases), gastroenteritis, vaginal infections, tooth infections, tonsillitis, and herpes infections—occurred more often in TYSABRI-treated patients than in placebo-treated patients. One opportunistic infection, a cryptosporidial gastroenteritis with a prolonged course, was observed in a patient who received TYSABRI in Study MS1
  • In Studies MS1 and MS2, an increase in infections was seen in patients concurrently receiving short courses of corticosteroids. However, the increase in infections in TYSABRI-treated patients who received steroids was similar to the increase in placebo-treated patients who received steroids
  • In a long-term safety study of patients, opportunistic infections (pulmonary mycobacterium avium intracellulare, aspergilloma, cryptococcal fungemia and meningitis, and Candida pneumonia) have been observed in <1% of TYSABRI-treated patients
  • Concurrent use of antineoplastic, immunosuppressant, or immunomodulating agents may further increase the risk of infections over the risk observed with use of TYSABRI alone
  • In Studies MS1 and MS2, the rate of any type of infection was approximately 1.5 per patient-year in both TYSABRI-treated patients and placebo-treated patients
  • In Study MS1, the incidence of serious infections was approximately 3% in TYSABRI-treated patients and in placebo-treated patients. Most patients did not interrupt treatment with TYSABRI during infections

Laboratory Test Abnormalities

  • In clinical trials, TYSABRI was observed to induce increases in circulating lymphocytes, monocytes, eosinophils, basophils, and nucleated red blood cells. Observed changes persisted during TYSABRI exposure, but were reversible, returning to baseline levels usually within 16 weeks after the last dose. Elevations of neutrophils were not observed. TYSABRI induces mild decreases in hemoglobin levels (mean decrease of 0.6 g/dL) that are frequently transient

Thrombocytopenia

  • Cases of thrombocytopenia, including immune thrombocytopenic purpura (ITP), have been reported with the use of TYSABRI in the postmarketing setting. Symptoms of thrombocytopenia may include easy bruising, abnormal bleeding, and petechiae. Delay in the diagnosis and treatment of thrombocytopenia may lead to serious and life-threatening sequelae. If thrombocytopenia is suspected, TYSABRI should be discontinued

Adverse Reactions

  • The most common adverse reactions reported at an incidence of ≥10% with TYSABRI and ≥2% difference with placebo were headache (38% vs 33%), fatigue (27% vs 21%), infusion reactions (24% vs 18%), urinary tract infections (21% vs 17%), arthralgia (19% vs 14%), depression (19% vs 16%), pain in extremity (16% vs 14%), rash (12% vs 9%), gastroenteritis (11% vs 9%), and vaginitis (10% vs 6%)
  • The most frequently reported serious adverse reactions in Study MS1 were infections (3.2% vs 2.6% placebo), including urinary tract infection (0.8% vs 0.3%) and pneumonia (0.6% vs 0%), acute hypersensitivity reactions (1.1% vs 0.3%, including anaphylaxis/anaphylactoid reaction [0.8% vs 0%]), depression (1.0% vs 1.0%, including suicidal ideation or attempt [0.6% vs 0.3%]), and cholelithiasis (1.0% vs 0.3%)
  • Based on animal data, TYSABRI may cause fetal harm. TYSABRI should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus

Please see full Prescribing Information, including Boxed Warning.

References: 1. Dutta R, Trapp BD. Mechanisms of neuronal dysfunction and degeneration in multiple sclerosis. Prog Neurobiol. 2011;93(1):1-12. 2. Trapp BD, Ransohoff RM, Fisher E, Rudick RA. Neurodegeneration in multiple sclerosis: relationship to neurological disability. Neuroscientist. 1999;5(1):48-57. 3. Giovannoni G, Butzkueven H, Dhib-Jalbut S, et al. Brain health: time matters in multiple sclerosis. Mult Scler Relat Disord. 2016;9(suppl 1):S5-S48. 4. Hutchinson M. Predicting and preventing the future: actively managing multiple sclerosis. Pract Neurol. 2009:9(3):133-143. 5. Mowry EM. Natural history of multiple sclerosis: early prognostic factors. Neurol Clin. 2011;29(2): 279-292. 6. Mitchell AJ, Benito-Leόn J, González JM, Rivera-Navarro J. Quality of life and its assessment in multiple sclerosis: integrating physical and psychological components of wellbeing. Lancet Neurol. 2005;4(9):556-566. 7. Scalfari A, Neuhaus A, Daumer M, Ebers GC, Muraro PA. Age and disability accumulation in multiple sclerosis. Neurology. 2011;77(13):1246-1252. 8. Kantarci O, Wingerchuk D. Epidemiology and natural history of multiple sclerosis: new insights. Curr Opin Neurol. 2006;19(3):248-254. 9. Coyle PK. Switching therapies in multiple sclerosis. CNS Drugs. 2013;27(4):239-247. 10. Mowry EM, Pesic M, Grimes B, Deen S, Bacchetti P, Waubant E. Demyelinating events in early multiple sclerosis have inherent severity and recovery. Neurology. 2009;72(7):602-608. 11. Bergamaschi R. Prognostic factors in multiple sclerosis. Int Rev Neurobiol. 2007;79:423-447. 12. Wingerchuk DM. Smoking: effects on multiple sclerosis susceptibility and disease progression. Ther Adv Neurol Disord. 2012;5(1):13-22. 13. Miller D, Barkhof F, Montalban X, Thompson A, Filippi M. Clinically isolated syndromes suggestive of multiple sclerosis, part I: natural history, pathogenesis, diagnosis, and prognosis. Lancet Neurol. 2005;4(5):281-288. 14. Zipoli V, Goretti B, Hakiki B, et al. Cognitive impairment predicts conversion to multiple sclerosis in clinically isolated syndromes. Mult Scler. 2010;16(1):62-67. 15. Marrie RA, Rudick R, Horwitz R, et al. Vascular comorbidity is associated with more rapid disability progress in multiple sclerosis. Neurology. 2010;74(13):1041-1047. 16. De Stefano N, Airas L, Grigoriadis N, et al. Clinical relevance of brain volume measures in multiple sclerosis. CNS Drugs. 2014;28(2):147-156. 17. Ferreira D, Voevodskaya O, lmrell K, et al. Multiple sclerosis patients lacking oligoclonal bands in the cerebrospinal fluid have less global and regional brain atrophy. J Neuroimmunol. 2014;274(1-2):149-154. 18. Dobson R, Ramagopalan S, Davis A, Giovannoni G. Cerebrospinal fluid oligoclonal bands in multiple sclerosis and clinically isolated syndromes: a meta-analysis of prevalence, prognosis and effect of latitude. J Neurol Neurosurg Psychiatry. 2013:84(8):909-914. 19. Villar LM, Masjuan J, González-Porqué P, et al. lntrathecal lgM synthesis is a prognostic factor in multiple sclerosis. Ann Neurol. 2003;53(2):222-226. 20. Jeffery DR. Early intervention with immunomodulatory agents in the treatment of multiple sclerosis. J Neurol Sci. 2002;197(1-2):1-8. 21. Lizak N, Lugaresi A, Alroughani R, et al; MSBase Study Group. Highly active immunomodulatory therapy ameliorates accumulation of disability in moderately advanced and advanced multiple sclerosis. J Neurol Neurosurg Psychiatry. 2017;88(3):196-203. 22. Comi G. Early treatment. Neurol Sci. 2006;27(suppl 1):S8-S12. 23. Filippi M, Horsfield MA, Morrissey SP, et al. Quantitative brain MRI lesion load predicts the course of clinically isolated syndromes suggestive of multiple sclerosis. Neurology. 1994;44(4):635-641. 24. Comi G. Shifting the paradigm toward earlier treatment of multiple sclerosis with interferon beta. Clin Ther. 2009;31(6):1142-1157. 25. Compston A, Coles A. Multiple sclerosis. Lancet. 2008;372(9648):1502-1517. 26. Fisniku LK, Brex PA, Altmann DR, et al. Disability and T2 MRI lesions: a 20-year follow-up of patients with relapse onset of multiple sclerosis. Brain. 2008;131(pt 3):808-817. 27. Leray E, Yaouanq J, Le Page E, et al. Evidence of two-stage disability progression in multiple sclerosis. Brain. 2010;133(pt 7):1900-1913. 28. Comi G, Radaelli M, Soelberg Sørensen P. Evolving concepts in the treatment of relapsing multiple sclerosis. Lancet. 2017;389(10076):1347-1356. 29. Rudick RA, Lee JC, Simon J, Fisher E. Significance of T2 lesions in multiple sclerosis: a 13-year longitudinal study. Ann Neurol. 2006;60(2):236-242. 30. Giorgio A, Stromillo ML, Bartolozzi ML, et al. Relevance of hypointense brain MRI lesions for long-term worsening of clinical disability in relapsing multiple sclerosis. Mult Scler. 2014;20(2):214-219. 31. Prosperini L, Gallo V, Petsas N, Borriello G, Pozzilli C. One-year MRI scan predicts clinical response to interferon beta in multiple sclerosis. Eur J Neurol. 2009;16(11):1202-1209. 32. Sormani MP, Gasperini C, Romeo M, et al; MAGNIMS study group. Assessing response to interferon-β in a multicenter dataset of patients with MS. Neurology. 2016:87(2):134-140. 33. Rudick RA, Polman CH. Current approaches to the identification and management of breakthrough disease in patients with multiple sclerosis. Lancet Neurol. 2009;8(6):545-559. 34. Freedman MS, Patry DG, Grand’Maison F, Myles ML, Paty DW, Selchen DH; Canadian MS Working Group. Treatment optimization in multiple sclerosis. Can J Neurol Sci. 2004;31(2):157-168. 35. Coyle PK, Foley JF, Fox EJ, Jeffery DR, Munschauer FE, Tornatore C. Best practice recommendations for the selection and management of patients with multiple sclerosis receiving natalizumab therapy. Mult Scler. 2009;15(suppl 4):S26-S36. 36. Río J, Nos C, Tintoré M, et al. Assessment of different treatment failure criteria in a cohort of relapsing-remitting multiple sclerosis patients treated with interferon β: implications for clinical trials. Ann Neurol. 2002;52(4):400-406. 37. Coyle PK. Switching algorithms: from one immunomodulatory agent to another. J Neurol. 2008;255(suppl 1):44-50.

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