In the 2-year AFFIRM pivotal trial:

Relapsing MS patients received 300 mg TYSABRI every 28 days (n=627) or placebo (n=315). Patients with PPMS, SPMS, and PRMS were excluded.

83% of patients taking TYSABRI had no sustained disability progression for 12 weeks vs 71% with placebo (primary endpoint: 17% vs 29%; p<0.001)1,2

QUALITY OF LIFE ANALYZED IN PATIENTS TREATED WITH TYSABRI

In 2 separate studies, patients taking TYSABRI reported statistically significant improvements in quality of life, with regard to health-related quality of life (HRQoL) and Quality of Life in Neurological Disorders (Neuro-QoL) scores

See AFFIRM pivotal trial data
 
Consider time to clinical response with TYSABRI
 

In an exploratory analysis of the pivotal trials, TYSABRI patients reported improved health-related quality of life (HRQoL) scores as early as 6 months after starting treatment3

Study description: A retrospective, exploratory analysis of the pivotal trials was performed to report the effects of TYSABRI on HRQoL as measured by the Short Form-36 (SF-36). Results shown below are exploratory outcomes of the AFFIRM trial.3,a

  • The SF-36 is a widely used, general HRQoL instrument that contains 36 items used to assess patients’ health status and its impact on their lives

aSF-36 HRQoL results are patient-reported.3

Study limitations:

  • Results are exploratory outcomes of the AFFIRM trial, and a number of calculations were made to evaluate data trends; therefore, marginal p values should be interpreted with caution
  • The standard minimally important difference cutoff of 5 points was derived from a disease-free population, thus it may be preferable to establish a minimally important difference in patients with RMS
  • Significance level for testing the difference between treatment groups was set at 0.05 with no correction for multiple analyses
  • HRQoL measures were completed at baseline and Weeks 24, 52, and 104. Earlier measures would have allowed better understanding of when patients might expect improvement after they start therapy, and testing between Weeks 52 and 104 would have provided insight into the stability of HRQoL benefits during the second year of treatment
  • HRQoL for 9% (8% TYSABRI, 10% placebo) of patients who withdrew from the study was not known. Reasons for discontinuation of TYSABRI were not collected

HRQoL improvements were observed with TYSABRI as early as 6 months after starting treatment and sustained out to 2 years3

Adapted from the American Medical Association by Wiley-Liss, Inc.

Bold rows with highlighted values: statistically significant compared with placebo.

Baseline scores and changes from baseline at Weeks 24, 52, and 104 are shown for all SF-36 scales.

bp<0.01.

cp<0.05.

dp<0.001.

Physical Function score was significantly greater at 6 months, 1 year, and 2 years (p<0.01) along with significant improvements in 6 of 8 individual HRQoL scales

Patients treated with TYSABRI reported mean improvements relative to placebo in a majority of scales by Year 2 (Week 104)3

Patients taking TYSABRI achieved significant improvements in the Physical Function, Role-Physical, General Health, Vitality, Social Function, and Role-Emotional scales at 2 years3

This study was funded by Biogen.

TYSABRI can produce clinically meaningful improvements in mental and social health4

Study description: MS PATHS (Multiple Sclerosis Partners Advancing Technology and Health Solutions) is an ongoing, multinational, multicenter study to generate and collect standardized patient data during routine office visits from a large real-world cohort of MS patients. The study investigated the experiences reported by patients after starting natalizumab (n=164) using standard Neuro-QoL assessments of 12 domains related to physical, mental, and social health.5,6

  • Data were collected at routine visits from the large, real-world cohort of MS patients known as MS PATHS using the previously validated Multiple Sclerosis Performance Test (MSPT)
  • Neuro-QoL scores from visits following natalizumab initiation were compared with baseline Neuro-QoL scores to calculate the annualized rate of change
    • Patients completed the Neuro QoL, a comprehensive, self-reported, computer-adaptive battery of assessments for 12 domains
    • In the Neuro QoL, standardized T-scores for each domain are derived from patient responses on a 5-point scale related to their feelings or functioning in the prior 7 days
  • To evaluate the clinical relevance of changes, analyses were also conducted in patients with impairment in Neuro-QoL domains at baseline, defined as a T-score ≥55 for each of the negatively worded domains or ≤45 for each of the positively worded domains
  • A clinically meaningful change for each domain was defined as ≥5-point change (≥0.5 standard deviation [SD]) in T-score from baseline, previously identified as the threshold of discrimination of a minimally important difference using different quality-of-life tools in chronic diseases

Study limitations:

  • This is a real-world study that lacks randomization, and the results thus may be impacted by unconsidered variables or incomplete adjustment
  • The specific contribution of expectation bias—where patients have the expectation of benefit with study treatment—cannot be parsed in this study
  • The standard cutoff of ≥5 points or half of standard deviation in T-score from baseline was used to establish clinically meaningful change. The cutoff was based on the estimated effect size from several studies that included a mixed population of patients with diverse chronic diseases as well as some patients with MS5,6

Adjusted annualized rates of change in Neuro-QoL T-scores across all domains4

Bold rows with highlighted values are statistically significant.

eDue to reconfiguration of the Multiple Sclerosis Performance Test during the course of this study, 14 of the 164 patients did not provide responses to two of the Neuro-QoL domains—(1) positive affect and well-being and (2) emotional and behavioral dyscontrol—resulting in a total of 150 individual patient responses for these two domains.

fRate and CI are based on a multivariate-adjusted mixed-effects regression model.

Patients treated with TYSABRI in the overall population improved in 8 of 12 Neuro-QoL domains vs baseline4

Patients treated with TYSABRI who had baseline Neuro-QoL impairment improved in 10 of 12 domains4

Clinically meaningful change in Neuro-QoL T-Scores (Overall Population)4

Bold rows indicate that more patients achieved clinically meaningful improvement than worsening.

  • More than 75% of patients treated with TYSABRI remained stable or improved in each of the assessed domains
  • A greater proportion of patients treated with TYSABRI reported clinically meaningful improvement than worsening for all domains except lower extremity function and participation in social roles and activities, for which an equal number of patients worsened and improved

TYSABRI was shown to produce clinically meaningful improvements in mental and social health4

NEXT: Peer Perspectives

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 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
  • Cases of neonatal thrombocytopenia, at times associated with anemia, have been reported in newborns with in utero exposure to TYSABRI. A CBC should be obtained in neonates with in utero exposure to TYSABRI

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.

AFFIRM=NAtalizumab Safety and EFFIcacy in Relapsing-Remitting Multiple Sclerosis; PPMS=primary progressive multiple sclerosis; SPMS=secondary progressive multiple sclerosis; PRMS=progressive relapsing multiple sclerosis; ARR=annualized relapse rate; RMS=relapsing multiple sclerosis; CI=confidence interval.

 

References: 1. TYSABRI Prescribing Information, Biogen, Cambridge, MA. 2. Polman CH, O’Connor PW, Havrdova E, et al; for the AFFIRM investigators. A randomized, placebo-controlled trial of natalizumab for relapsing multiple sclerosis. N Engl J Med. 2006;354(9):899-910. 3. Rudick RA, Miller D, Hass S, et al; for the AFFIRM and SENTINEL Investigators. Health-related quality of life in multiple sclerosis: effects of natalizumab. Ann Neurol. 2007;62(4):335-346. 4. Hersh C, Kieseier B, de Moor C, et al. Impact of natalizumab on quality of life in a real-world cohort of patients with multiple sclerosis: results from MS PATHS. Mult Scler J Exp Transl Clin. 2021;7(2):1-13. doi:10.1177/20552173211004634. 5. Mowry EM, Krupp LB, Bermel R, et al. The Multiple Sclerosis Partners Advancing Technology and Health Solutions (MS PATHS) Patient Cohort. Poster presented at: 7th Joint ECTRIMS-ACTRIMS Meeting; October 25-28, 2017; Paris, France. 6. Norman GR, Sloan JA, Wyrwich KW. Interpretation of changes in health-related quality of life: the remarkable universality of half a standard deviation. Med Care. 2003;41(5):582-592.

 

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