3rd Nordic MS Symposium. Understanding progressive MS

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1 3rd Nordic MS Symposium Understanding progressive MS Copenhagen January 30 31, 2015

2 3rd Nordic MS Symposium Understanding progressive MS Symposium Copenhagen January 30 31, 2015 The 3rd Nordic MS Symposium focused on progressive MS, a disease form that represents a huge unmet medical need. To date, even the definition of this clinical phenotype, including what is progression and what is not, remains unclear. The same applies to what is (or what is not) incomplete remission. Uncertainties also remain regarding pathogenesis. Furthermore, treatment options are scarce. Fortunately, clinicians and researchers in the field are now focusing more of their efforts on progressive MS, and much is being achieved. This greater interest was also reflected at this year s symposium, which attracted the largest number of attendants thus far. This report presents the symposium s main findings. Professor Finn Sellebjerg Danish Multiple Sclerosis Center, Rigshospitalet University of Copenhagen, Denmark Contents WHAT IS PROGRESSIVE MS? SESSION I Chairman: Professor Finn Sellebjerg, Danish Multiple Sclerosis Center, Rigshospitalet, University of Copenhagen, Denmark Alan Thompson Evolution of primary and secondary progressive MS... 3 Christine Stadelmann-Nessler Pathological correlates of disease progression in MS... 5 Fredrik Piehl Adaptive vs. innate inflammation and relation to... 7 neuraxonal damage during different stages of MS Jack van Horssen Mitochondrial and oxidative damage in progressive MS... 8 MEASURING PROGRESSIVE MS SESSION II Chairman: Senior Neurologist Elisabeth Gulowsen Celius, Oslo University Hospital, Ullevål, Norway Mads Ravnborg From clinical scales to patient-reported outcomes... 9 Massimo Filippi Understanding the disease using modern MR techniques Päivi Hämäläinen Neuropsychological profiles in MS Sigrid Aune de Rodez Benavent Optical coherence tomography in progressive MS BIOMARKERS SESSION III Chairman: Professor Emeritus Oluf Andersen, Sahlgrenska University Hospital, Sweden Finn Sellebjerg Understanding progressive MS immunological biomarkers Sanna Hagman Young neurologists session: Adipokines in multiple sclerosis Signe Modvig Young neurologists session: CSF prognostic biomarkers in optic neuritis MONITORING MS SESSION IV Chairman: Professor Finn Sellebjerg, Danish Multiple Sclerosis Center, Rigshospitalet, University of Copenhagen, Denmark Helen Tedeholm Can we delay the onset of progressive MS? Jeremy Chataway Trials, tribulations and solutions in progressive multiple sclerosis Sten Fredrikson Management of progressive MS This publication reflects the views and experiences of the lecturers, and not necessarily those of the company. Text: Helena Nordlund, Michael Wainwright/Transgraf Graphic design: Sylvia Sveicers/Transgraf THE TOPICS AND AGENDA WERE DRAWN UP BY AN INDEPENDENT STEERING COMMITTEE: Finn Sellebjerg, Professor, Dept. of Neurology, Rigshospitalet, Copenhagen, Denmark Oluf Andersen, Professor emeritus, Sahlgrenska University Hospital, Sweden Irina Elovaara, Professor, Tampere University Hospital, Finland Elisabeth Gulowsen Celius, Senior Neurologist, Oslo University Hospital Ullevål, Norway 2

3 Understanding progressive MS 3 rd Nordic MS-Symposium WHAT IS PROGRESSIVE MS? SESSION I Evolution of primary and secondary progressive MS Professor Alan Thompson, University College London, Institute of Neurology, London, GB Alan Thompson described the journey of progressive MS from the wilderness and into the limelight. He then outlined the work of the Progressive MS Alliance and how it is contributing to continued development. The article that may be one of the first descriptions of primary progressive MS (PPMS) in the literature was published in 1903 (Mills CK, Spiller WG. J Nerv Ment Dis 1903; 30: ) and in 1957, the progressive form of the disease was described (McAlpine D. Br Med J 1957; 1: ). A classification introducing the notion of progressive possible and progressive probable MS was published in 1977 (McDonald WI, Halliday AM. Br Med Bull 1977; 33: 4 9), followed by the well-known Poser criteria in 1983 (Poser CM et al. Ann Neurol 1983; 13: ). The terms primary progressive (PP) and secondary progressive (SP) MS were first introduced in 1989 (Thompson AJ et al. Lancet 1989; 1: ). Some ten years later, diagnostic criteria for PPMS were proposed (Thompson AJ et al. Ann Neurol 2000; 47: 831 5), after which they were incorporated into the first set of McDonald criteria (McDonald WI et al. Ann Neurol 2001; 50: 121 7). The McDonald version now in use was published in 2011 and includes updated criteria for PPMS (Polman CH et al. Ann Neurol 2011; 69: ). Evolving understanding The vast majority of patients with progressive MS begin with a relapsing form and convert to a progressive form. Only a small percentage displays nearly continuous progression of disability with no distinct relapses. Whether these forms represent different disease entities or different conditions within the same disease spectrum is not absolutely determined but the latter is strongly favoured. According to the MS International Federation, the global prevalence of MS is approx. 2.3 million and more than half have progressive disease ( About a dozen different therapeutic options are currently available for RRMS, but there is no effective treatment for progressive forms. As the disease changes towards secondary progression, MRI activity appears to decrease. However, there is a steady reduction in brain volume from the outset, suggesting that progression starts already at the beginning of disease. Development of secondary progression is the dominant determinant of longterm prognosis, independent of disease duration and early relapse frequency (Scalfari A et al. Neurology 2011; 77: ). When UK patients were asked to define the most urgent disease areas, treating progression was their highest priority (www. mssociety.org.uk) MS clinical description subtypes 2013 MS disease modifiers phenotypes PP Progressive accumulation of disability from onset with or without temporary plateaus, minor remissions and improvements Progressive accumulation of disability from onset Active and with progression Progressive disease SP Progressive accumulation of disability after initial relapsing course, with or without occasional relapses and minor remissions (PP) Progressive disease Active but without progression Not active but with progression PR Progressive accumulation of disability from onset but clear acute clinical attacks with or without full recovery (SP) Progressive accumulation of disability after initial relapsing course Not active and without progression (stable disease) Figure 1. The 1996 and 2013 MS phenotype descriptions for progressive disease (modified from Lublin FD et al. Neurology 2014; 83: ). 3

4 3 rd Nordic MS-Symposium Understanding progressive MS WHAT IS PROGRESSIVE MS? SESSION I Pathological mechanisms To identify targets for treatment of progressive MS, the pathological mechanisms underpinning progression need to be clarified. There is currently no universal definition of progressive MS. A neurologist may describe accumulation of disability or gradual worsening over time, a pathologist axonal or oligodendrocyte pathology. An imager, on the other hand, may focus on progressive atrophy and expanding lesions, while a patient would highlight loss of independence, inability to work and worsening of symptoms. A consensus document defining the clinical course of MS, first published in 1996 and revised in 2013, shows that the older description focused on progression of disability whereas the newer is more focused on the concept of disease activity (Fig. 1). Challenges Much work is currently carried out in the field of biomarkers as clinical outcome measures. The MS Outcome Assessments Consortium, among others, aims to accelerate the development of new therapies by generating new tools for measuring outcomes in clinical trials (Rudick RA et al. Mult Scler 2014; 20: 12 7). One design that would increase the efficiency of clinical trials in SPMS has been suggested (Chataway J et al. Mult Scler 2011; 17: 81 8). It involves adaptive seamless design (ADS) to test multiple candidate compounds using an interim decision point that allows potentially effective therapies to be taken into the next design stage and to be assessed using a phase III outcome. Compared to conventional designs, ADS can lead to sample size savings of up to 40%. A large number of trials in progressive MS are currently underway and some have already been completed. An interesting example is the randomized, placebo-controlled, phase II MS- STAT trial, in which high-dose simvastatin was shown to reduce whole-brain atrophy compared with placebo (Chataway J et al. Lancet 2014; 383: ). Progressive MS Alliance The International Progressive MS Alliance, supported by MS societies and the Multiple Sclerosis International Federation (MSIF), was established in 2012 as a global initiative to drive Experimental models Identification and validation of targets and repurposing Proof-of-concept clinical trial strategies Clinical outcome measures Symptom management and rehabilitation Figure 2. Five key research priorities for progressive MS (modified from Robert J Fox et al. Mult Scler 2012; 18: ). the development of new treatment options for progressive MS ( The Alliance works to bring together the world s leading experts and key opinion leaders in MS to identify and address critical scientific and regulatory obstacles in order to achieve breakthroughs in progressive MS. Managing members are Australia, Canada, Italy, UK, USA and the MSIF. The Alliance has a growing number of member organizations from around the world and aims to be the common bond that strengthens impact and progress. For the first time ever, MS societies are funding research together without considering geography simply supporting the best science anywhere in the world. A study initiated by MSIF aiming to review current challenges in developing therapies for progressive MS has identified five priority research areas (Fig. 2). To better understand the global research landscape, i.e. what is being funded and what gaps remain, research-funding data have been collected from the members and analyzed to assess the research portfolio. A total of 707 projects funded by the Alliance s managing members were identified, with a total commitment of about 231 million USD. Pushgraph technology was applied to identify projects relevant to progressive MS by determining thematic and semantic similarities in project titles, abstracts and keywords. Of the 707 projects, 405 were identified as relevant to progressive MS, with a total commitment of about 132 million USD (NMSS, unpublished data). Two sets of collaborative network awards have been initiated, both designed to accelerate the development of therapies for progressive MS: RFA1 and 2. RFA1 received 195 applications, of which 22 projects from eleven countries were approved for funding. Research areas covered are underlying pathology of progression, gene studies, developing new disease models, clinical trials and outcome measures/biomarkers, and rehabilitation trials. RFA2, which closed in January 2015, is supporting collaborative networks focusing on drug discovery programs, biological or imaging biomarkers, and proof-of-concept trials. Another important initiative is the formation of a working group to address symptom management and rehabilitation strategies in progressive MS. A third party to be included in the Progressive MS Alliance is the pharmaceutical and biotechnology industry a partnership that is critical for success. An Alliance and Industry Alignment meeting was held in December 2014 and 12 major companies involved in MS participated. A good summary of the current knowledge in this field with regard to pathological mechanisms, treatment and clinical trials can be found in a recently published three-part series in Lancet Neurology (Mahad DH et al. 2015; 14: , Feinstein A et al. 2015; 14: , Ontaneda D et al. 2015; 14: ). 4

5 Understanding progressive MS 3 rd Nordic MS-Symposium WHAT IS PROGRESSIVE MS? SESSION I Pathological correlates of disease progression in MS Professor Christine Stadelmann-Nessler, Institute of Neuropathology, University Medical Center, Göttingen, Germany Secondary progressive MS appears non-inflammatory on MRI, and this has stimulated the concept of neurodegeneration as the cause. Pathologically, however, inflammation and demyelination are still important features of this disease phase. Christine Stadelmann-Nessler discussed various aspects of progressive MS pathology. In progressive MS, new and active demyelinating lesions are exceedingly rare. Instead, diffuse injury of the normal-appearing white matter (NAWM) and cortical demyelination are characteristic hallmarks (Kutzelnigg A et al. Brain 2005; 128: ). The non-focal pathology is accompanied by a certain inflammatory response, composed of CD8 and CD4 T cells and microglial activation, and accompanied by loss of axons plus a certain degree of acutely ongoing axonal damage in the NAWM. These subtle changes are certainly not very prominent but they do accumulate over decades, thereby contributing to disease progression. Cortical demyelinated lesions Of the putative pathological correlates of disease progression, cortical demyelinated lesions affect more than 90% of patients with MS (Albert M et al. Brain Pathol 2007; 17: ). It is possible that cortical lesions can reveal information about the pathogenic mechanisms of MS and that these mechanisms can be targeted. Although late-stage (progressive) MS is much more characterized by cortical demyelinated lesions, subpial demyelination is also present in very early disease (Lucchinetti CF et al. N Engl J Med 2011; 365: ). Quantitatively, subpial lesions are the most extensive, covering up to 70 % of the area in some progressive patients (Kutzelnigg A, Lassmann H. J Neurol Sci 2005; 233: 55 9). Subpial demyelination is also the most characteristic for MS; the only similar pathological changes are seen with JC virus infection in the upper layer of the cortex, but this is hardly likely to be a differential diagnosis for MS. The cortex appears to remyelinate more easily than the underlying white matter (Albert M et al. Brain Pathol 2007; 17: ). To investigate this further, a focal EAE model of cortical demyelination in the Lewis rat was developed (Merkler D et al. Brain 2006; 129: ). In this model, remyelination was shown to be more rapid and more complete in the cortex than in the underlying white matter. These findings are in line with a more recent study reporting greater remyelination, more actively remyelinating oligodendrocytes, and fewer reactive astrocytes in demyelinated lesions involving the cortex (Chang A et al. Ann Neurol 2012; 72: ). Astrocytes in the white matter, but not in the cortical portions of these lesions, were shown to significantly upregulate CD44, hyaluronan and versican, three molecules that form complexes that inhibit oligodendrocyte maturation and remyelination. Thus, the cerebral cortex shows high propensity for remyelination, whereas widespread subpial cortical demyelination is a common feature in progressive MS and can be found already in early disease stages. It appears, however, that cortical demyeli- Survival (%) Survival (%) Age at death (years) Disease duration (years) Figure 1. In a study on PPMS, clinicopathological comparisons revealed that a more severe clinical course was associated with greater inflammation at death (modified from Choi SR et al. Brain 2012; 135: )

6 3 rd Nordic MS-Symposium Understanding progressive MS WHAT IS PROGRESSIVE MS? SESSION I Active lesion Slowly expanding Inactive lesion NAWM multiple White matter lesion sclerosis controls Median P value Median P value Median P value Median P value Median (range) (range) (range) (range) (range) Percentage of E (26.5) (16.7) (9.2) (17.1) (2.9) positive area E06 axon spheroids 1.3 (18.2) (121.2) (2.3) (1.2) (0.0) MDA-2 OG 1.6 (25.8) (5.4) (1.6) (9.2) (1.6) 8-OHdG nuclei 5.6 (78.1) (19.0) (6.8) (12.0) (10.4) APP 44.3 (197.6) (40.0) (1.5) (1.0) (0.8) CD (298.8) (105.6) (69.1) (38.4) (49.6) HLA-D (585.6) (398.0) (246.5) (190.0) (114.4) Figure 2. Quantification of oxidized lipids and oxidized DNA in different types of MS lesions in comparison with controls (modified from Haider L et al. Brain 2011; 134: ). nation and white matter lesions have the same principal underlying mechanisms. We know that progressive MS is not completely non-inflammatory. The extent of inflammation in the meninges has been shown to correlate with the number and extent of white matter lesions, especially subpial lesions, with T cells as the predominant cell type (Howell OW et al. Brain 2011; 134: ). Meningeal and diffuse NAWM inflammation The degree of generalized diffuse meningeal inflammation in PPMS has been shown to be associated with a more severe clinical course and shorter survival (Fig. 1). Association, however, is not necessarily causation. Based on the results form the INFORMS trial, in which fingolimod failed to slow the progression of sustained disability any better than placebo in patients with PPMS (Miller DH et al. AAN 2013; P07.116), it seems unlikely that T cells would somehow drive the disease or even be harmful. Chronic active smouldering lesions Actively demyelinating lesions dominate in the early, relapsingremitting stage of MS (RRMS). In progressive disease, active white matter lesions are practically non-existent while inactive white matter lesions predominate. Slowly expanding white matter lesions (so-called smouldering brain lesions) are also quite frequent (Kutzelnigg A et al. Brain 2005; 128: ). The rims of smoldering lesions contain activated microglia/ macrophages and damaged axons, indicating recent demyelination. In addition, T cells are found perivascularly, but their role remains to be investigated. Figure 2 shows quantification of oxidized lipids and oxidized DNA in different types of MS lesions in comparison with controls. Axonal loss is more pronounced in late-stage spinal lesions, but even established chronic lesions without much inflammatory infiltration display some amount of acute axonal damage that, by accumulating over time, contributes to continuous clinical worsening (Schirmer L et al. Brain Pathol 2011; 21: ). A close association between inflammation and neurodegeneration is seen in all lesions and disease stages of MS (Frischer JM et al. Brain 2009; 132: ). Chronic lesions display increased mitochondrial activity, since demyelinated axons require an increased energy supply. A study to investigate if neuronal loss contributes to progression examined spinal cord tissue from 30 clinically wellcharacterized MS patients (Schirmer L et al. Ann Neurol 2009; 66: ). Results showed that chromatolytic neurons and immunoreactivity for the immediate early gene c-jun, a damage-response marker, and GAP43, indicating a regenerative response, were present in the ventral grey matter in and adjacent to actively demyelinating lesions, indicating neuronal damage and regeneration as an early response to lesion formation. Future challenges The presence of adaptive inflammation in chronic MS brains is puzzling. We clearly need to increase our understanding of the type of adaptive and innate inflammation present in chronic disease through detailed analysis of tissue, CSF and serum. We also need to better understand the type of neuroaxonal damage relevant for disability it may not always be a matter of neuroaxonal loss only, but also of atrophy and dysfunction. 6

7 Understanding progressive MS 3 rd Nordic MS-Symposium WHAT IS PROGRESSIVE MS? SESSION I Adaptive vs. innate inflammation and relation to neuraxonal damage during different stages of MS Professor Fredrik Piehl, Dept. of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden Fredrik Piehl described the role of adaptive and innate inflammation and emphasized patient age rather than disease duration as a negative predictive factor. Younger patients display more inflammatory activity and more nerve injury than older patients, and age shows strong negative correlation to all CSF biomarkers, including inflammatory ones (Khademi M et al. PLoS One 2013; 8: e63172). Disease-modifying treatment (DMT) appears to be more effective in younger patients. In a large European register study, chronological age was a more important determinant of relapse incidence than disease duration (Kalincik T et al. Brain 2013; 136: ). A Swedish study based on the national natalizumab cohort shows that younger patients (<50 years) increase more in Symbol Digit Modality Test (SDMT) scores after starting treatment than older patients (Matell H et al. Mult Scler 2015; 21: 48 56). It has not been clearly established if patients with progressive disease without signs of inflammation are helped by DMTs. Most studies are too small for any firm conclusions to be drawn. However, the few large studies that have been carried out show at least some tendency towards effect; if patients were stratified for inflammatory signs on MRI, biomarkers or age, some treatments would probably show efficacy. Adaptive immunity can also be important in progressive disease. For example, a one-year study on natalizumab in SPMS showed that some patients had elevated levels of neurofilament and achieved treatment results similar to those in RRMS (Romme Christensen J et al. Neurology 2014; 82: ). Several mechanisms common for many chronic neurodegenerative diseases may be of importance. A review article highlights oxidative stress leading to mitochondrial injury as a possible culprit in both progressive disease and RRMS (Lassmann H et al. Nat Rev Neurol 2012; 8: ). One effort to prove this hypothesis is the EU-funded Neurinox project, in which a large number of NOX enzymes will be genotyped and functional oxidative burst assays carried out ( Early relapses lead to significant loss of axonal connections, and progression continues even if the inflammation is reduced. Disease development is illustrated in Figure 1. Physical activity a possible confounder A recent Swedish animal study shows that exercise training enhances the conversion of kynurenine to kynurenic acid, a metabolite unable to cross the blood brain barrier. Reduced plasma levels of kynurenine protect the brain from stress-induced changes associated with depression (Agudelo LZ et al. Cell 2014; 159: 33 45). Human data are still lacking but this certainly warrants further study also within MS. Synapse plasticity is regulated by activity, which is in part mediated by MHC class I expression and the complement system (Oliveira AL et al. Proc Natl Acad Sci U S A 2004; 101: ). In MS, this raises questions regarding the role of physical activity in synaptic pruning and how the brain is affected by increasing disability and inactivity; what damage is caused by active disease processes and what is simply deconstruction of a nervous system that is not being used? Relapses and clinical disability Inflammatory activity Early RR phase Late RR phase SP phase Adaptive immunity Adaptive Amendable to treatment Ageing Adaptive (more B cell?) Innate/repair Innate/local tissue response Figure 1. MS development and the immune response (modified from Piehl F. J Intern Med 2014; 275: ). 7

8 3 rd Nordic MS-Symposium Understanding progressive MS WHAT IS PROGRESSIVE MS? SESSION I Mitochondrial and oxidative damage in progressive MS Professor Jack van Horssen, PhD, MS Center Amsterdam, VU University Medical Center, Amsterdam, Holland Jack van Horssen explained how free radicals are produced by specific enzymes and defective mitochondria in MS brain tissue and how this phenomenon can be used for therapeutic targeting. Free radicals or reactive oxygen species (ROS) play an important role in many processes, including MS lesion formation and progression. Microarray analysis of early lesions shows that several enzymes involved in ROS production are significantly enhanced (Lassmann H et al. Neuropathol Appl Neurobiol 2011; 37: ). One example is the genes that encode subunits of NADPH oxidase, a complex of proteins that are important under inflammatory conditions. In a study carried out at VU Medical Center, up-regulation of several members of the NADPH oxidase family was demonstrated using immunohistochemistry (IHC) and western blotting (Fischer MT et al. Brain 2012; 135: ). This was postulated as evidence for an oxidative burst in microglia and macrophages in active MS lesions that contributes to oxidative damage and may constitute a therapeutic target. Studies investigating such therapeutic possibilities have been carried out (e.g. Li S et al. Neuroscience 2011; 184: ), but the animal models used thus far do not represent the pathological characteristics seen in progressive MS, especially with meningeal inflammation (CSF) activation of cortical microglia mitochondrial defects neurodegeneration cortex white matter OxPhos antioxidants UCPs PGC-1α i i microglia Figure 1. The current working model for neurodegeneration as a new pathogenic concept in progressive MS. Meningeal inflammation gives rise to proinflammatory cytokines and cytotoxic molecules within the cerebrospinal fluid. These molecules activate cortical microglia, which produce proinflammatory cytokines that induce mitochondrial alterations, leading to neurodegeneration (J van Horssen 2015). TNFα ROS NO neuron regard to amplification of oxidative damage (Schuh C et al. Acta Neuropathol 2014; 128: ). A potentially better alternative may be the marmoset EAE model, which displays several pathological hallmarks of progressive MS. Mitochondrial dysfunction Neurons, highly dependent on aerobic respiration, are packed with mitochondria, which are one of the most important sources of free radicals. In the electron transport chain, some electrons leak out and react with oxygen, leading to production of ROS within the mitochondria, especially under pathological conditions. The mitochondria, however, have a protection system consisting of several antioxidant enzymes. Expression of mitochondrial antioxidant enzymes has been shown to be reduced in the cortex of progressive MS patients, even in areas with no signs of demyelination (Witte ME et al. Acta Neuropathol 2013; 125: ). In search for transcriptional dysregulation we identified PGC-1α, a transcriptional co-activator and master regulator of mitochondrial function to be partly responsible for the significant reduction of mitochondrial antioxidants in MS grey matter (Witte ME et al. Acta Neuropathol 2013; 125: ). Neurons with reduced PGC-1α levels display severe mitochondrial defects and are more vulnerable to oxidative damage and proinflammatory cytokines. Current research efforts are focused on understanding why PGC-1α is down-regulated in MS. Inflammation is one factor known to exert this effect in cardiac and skeletal muscles, e.g. in the form of TNF-α. When primary neurons are treated with TNF-α for a prolonged time, both PGC-1α and the antioxidant enzymes driven by PGC-1α are down-regulated (unpublished data). New therapeutic strategies targeting mitochondrial dysfunction and ROS include NADPH oxidase inhibition, mitochondria-targeted antioxidants, PGC-1α activators and Nrf2 inducers to increase oligodendrocyte antioxidant enzyme production. A further strategy would be to find new ways of interfering with TNF, possibly by targeting TNF receptor 1. The current working model for progressive MS is shown in Figure 1. 8

9 Understanding progressive MS 3 rd Nordic MS-Symposium MEASURING PROGRESSIVE MS SESSION II From clinical scales to patient-reported outcomes Dr Mads Ravnborg, Department of Neurology, Odense University Hospital, Denmark Mads Ravnborg described how clinical scales for MS are developed and compared EDSS to MSIS. MS rating scales are used for measuring the consequences of pathology in the form of symptoms and impairment. Both factors may influence activity and social participation. As a logical consequence, quality of life (QoL) is affected (Fig. 1). When developing a scale, the trait to be addressed must be selected, e.g. anxiety. The chosen trait is then accessed through a number of items, e.g. sport. This item is presented together with a vector, e.g. a question on how important it is to be able to participate in sports. Items are usually grouped into domains. The type of scaling to be used must also be determined, e.g. if the responder agrees/partly agrees/does not agree, yes/no, etc. Next, the scale must be validated and its reliability confirmed. Finally, its responsiveness for the trait to be measured must be established. Health measurement scales should be exhaustive, non-redundant, without floor or ceiling effects, linear in responsiveness, and mono-dimensional. EDSS The Expanded Disability Status Scale (EDSS) comprises three subscales: impairment (range 0 5), ambulation (4.5 8) and ADL functions (7 9.5). Known key weaknesses include an overlap between the subscales that makes it impossible to know which domain is affected, adjectival grading (slight/moderate/ severe) and non-linear responsiveness. Moreover, inter-rater variability is high as the examination is non-standardized. MSIS In contrast, the MS Impairment Scale (MSIS) is a standardized examination with no interpretation. This was achieved by defining a scale of the smallest clinically detectable steps of abnormality for the traits examined. MSIS comprises 53 items with a sum score in the interval 0 202, with 0 signifying normality. Rating is strictly objective, with the assessment restricted to the impairment dimension and the steps defined by means of a qualitative rather than quantitative glossary. The main advantages of MSIS compared to EDSS are a low degree of data reduction and low redundancy, a small floor and ceiling effect, and more linear responsiveness. A study comparing the responsiveness of EDSS and MSIS showed a more stable variance of the annualized change in MSIS, indicating better responsiveness in terms of both magnitude and stability over the range of measurements (Ravnborg M et al. Mult Scler 2005; 11: 81 4). Choosing study outcomes In clinical trials on MS, which outcomes are most suitable depends on the clinical phenotype. Studies on treatment effects in CIS patients primarily rely on changes in pathology; consequences in the form of impairment and symptoms are secondary parameters. For RRMS, impairment is the most trustworthy primarily outcome, with MRI and symptoms as secondary parameters. Impairment should also be the primary outcome for early SPMS, with activity, MRI changes and symptoms as suitable secondary outcomes. In SPMS extension studies, QoL may be added as a secondary outcome as there is more time to accrue changes. For MS rehabilitation studies, activity appears to be the most appropriate primary outcome and social participation the best secondary outcome. It must be recognized, however, that no clinical assessment scale is better than the neurologist who administers the test, and that expert validation is crucial. Symptoms QoL Social participation Activity Pathology Impairment Figure 1. MS pathology may give rise to symptoms and impairment but does not directly influence activity, which is instead a result of symptoms and impairment. Similarly, impairment in itself does not affect QoL, whereas symptoms, e.g. pain, may do so (modified from International Classification of Functioning, Disability and Health (ICF), WHO 2001). 9

10 3 rd Nordic MS-Symposium Understanding progressive MS MEASURING PROGRESSIVE MS SESSION II Understanding the disease using modern MR techniques Professor Massimo Filippi, Neuroimaging Research Unit, Vita-Salute San Raffaele University, Milan, Italy Recent years have seen impressive advances in the implementation of modern MR assessment techniques and several new ones are emerging, bringing additional promise for improving our understanding of MS pathophysiology. T2 lesions The number of MS lesions was previously believed to plateau when patients enter the secondary progressive phase, but additional work now indicates that some accrual of T2 lesions can indeed be detected during this phase. This is particularly true if the follow-up assessment time is prolonged (e.g. Goodin DS et al. BMJ Open 2012; 2: pii: e001972). Atrophy Assessing atrophy with MR is becoming a popular way of determining the status and evolution of MS, especially in the progressive phase. Atrophy appears to be more widespread in SPMS compared to clinically isolated syndrome (CIS), but when rates are corrected for baseline brain volume, a majority of patients follow the disease course with an annual 0.5% loss of brain tissue, independent of the clinical phenotypes. This suggests that atrophy is a continuous phenomenon starting very early in the disease course (De Stefano N et al. Neurology 2010; 74: ). Grey matter atrophy is more strongly related to physical disability and cognitive impairment than white matter atrophy across different disease phenotypes (Roosendaal SD et al. Mult Scler 2011; 17: ). Several studies have demonstrated that grey matter atrophy rates can predict disease evolution from CIS to RRMS and from RRMS to SPMS much better than white matter atrophy (e.g. Fisher E et al. Ann Neurol 2008; 64: ). Normal-appearing white matter damage Diffusivity measurements in normal-appearing white matter (NAWM) in patients with different disease phenotypes show a trend towards a loss of microstructural organization that increases with more progressive disease stages (Pulizzi A et al. Arch Neurol 2007; 64: ). During recent years, much knowledge has been gained through the use of new techniques like diffusion tensor tractog- raphy. For example, it has become possible to topographically map the location of microstructural damage in the brain in different MS phenotypes. This technique can also be used to assess how brain damage builds up as the disease evolves (Mesaros S et al. Neurology 2012; 78: ). Grey matter involvement: cortical lesions and diffuse damage Subpial cortical lesions are still difficult to detect with MR a major drawback of this technique. However, the ability to detect such lesions was much improved with the use of double inversion-recovery (DIR) sequences, and even further enhanced with ultra-high field MRI. A study using this technique for visualizing MS cortical lesions and comparing the results with previous pathological literature showed that the relative percentages of the different histologic lesion types were similar to that of pathology (Mainero C et al. Neurology 2009; 73: 941 8). Thus, even if all cortical lesions are still not detected using MR, it seems they are detected in the right proportions. Cortical lesions are clinically relevant. Several large studies in PPMS and RRMS patients have established the amount of cortical lesions present at baseline as an independent predictor of CSA (mm 2) ,0 CTRL BMS CIS RR PP SP CSA vs EDSS: r= -0.49, p< ,2 0,4 0,6 0,8 1,0 Normalized distance along the cord Figure 1. Spinal cord damage, measured as cervical cord cross-sectional area (CSA) in MS patients with different clinical phenotypes. Note that the curves remain parallel (modified from Rocca MA et al. Neurology 2011; 76: ). 10

11 Understanding progressive MS 3 rd Nordic MS-Symposium MEASURING PROGRESSIVE MS SESSION II subsequent progression of disability over 2 3 years (Calabrese M et al. Neurology 2009; 72: , Calabrese M et al. Ann Neurol 2010; 67: ). A different approach to quantifying the extent of grey matter damage is to segment grey matter and measure diffusivity and/ or the magnetization transfer ratio (MTR). Diffuse grey matter damage is a combined measure of detectable and non-detectable lesions and Wallerian degeneration. A longitudinal study of 73 RRMS patients showed that grey matter atrophy/damage could predict worsening of disability, evolution to SPMS and cognitive deterioration 13 years later (Filippi M et al. Neurology 2013; 81: ). Brain regional and spinal cord damage Different parts of the CNS are differently eloquent in terms of determining clinical outcomes. For example, hippocampal atrophy, which is especially pronounced in progressive MS, has been shown to correlate with deficits of memory and visuospatial learning (Longoni G et al. Brain Struct Funct 2015; 220: ). Similarly, thalamic damage and volume reduction correlates with both impaired cognitive performance and disability (e.g. Rocca MA et al. Radiology 2010; 257: 463 9). Until a few years ago, the spinal cord was difficult to image correctly, but several methods have now been developed. For example, a study using 3T MRI showed a clear association between cervical cord lesion load and disability in MS, independent of atrophy (Kearney H et al. Neurology 2015; 84: ). In a study applying voxel-based methods, the greatest cervical cord damage was seen in patients with SPMS (Rocca MA et al. J Neurol Neurosurg Psychiatry 2013; 84: 35 41). Interestingly, probability maps showed that the amount of T2 lesions in the upper cervical cord did not completely match atrophy, suggesting that atrophy is more driven by degeneration of long fiber tracts to or from the brain than by focal lesions in the cord. According to a multicenter study, a new semi-automatic method for segmenting the cervical cord from C2 to C5 can be used as a marker for characterizing clinical heterogeneity in MS (Rocca MA et al. Neurology 2011; 76: ). The profile of atrophy along the cervical cord in patients with different clinical phenotypes is shown in Figure 1. The measure proved to be stable among participating centers, supporting its use as a potential outcome measure to monitor disease progression in multicenter trials. In phase II trials, it could potentially reduce the number of patients required by about half. CNS reorganization Functional MRI can be used to assess cortical reorganization. In early disease, more areas typically appear to be devoted to HCs RRMS BMS SPMS L SFG Figure 2. CNS reorganization in patients with different MS phenotypes compared to healthy controls using resting-state functional MRI and graph theory (modified from Rocca MA et al. Brain Struct Funct 2014, Epub ahead of print). a given task. As the disease progresses, bilateral activation of these regions is seen and in later stages, areas that healthy people recruit for novel or complex tasks are activated even for very simple ones. Thus, abnormalities in the brain s ability to react functionally to increasing tissue damage appear to be critical in causing the final clinical outcome in MS patients. Resting-state functional MRI using graph theory can be used to explore the topological organization of functional brain network connectivity and get important clues on CNS reorganization. A study estimating functional connectivity between 116 cortical and subcortical brain regions displayed regional redistribution and impaired functional integration of network properties, contributing to cognitive status and phenotypic variability (Rocca MA et al. Brain Struct Funct 2014, Epub ahead of print). Depending on the disease phenotype, some network hubs are lost while others are new, presumably to compensate for such a loss (Fig. 2). MCC Put Thal ACC MTG ACC Conclusions MR comprises multiple techniques that can be applied in different phases of MS. For example, typical MR outcomes, like Gd-enhancement or T2 lesion accumulation, are appropriate at the beginning of the disease, when inflammation abounds, and when investigating anti-inflammatory drugs. To measure potential neuroprotective treatment effects, other MR approaches are likely more appropriate. Precun Cer-crus-I ITG Cer-crus-II MCC MTG Cer-crus-I SupTP ITG Cer-crus-II MCC Thal MTG Cer-lobule-IV V SupTP ITG Cer-crus-I Cer-crus-II Cer-lobule-VIII MTG SupTPThal Ling Cer-lobule-IV V PHG Cer-crus-I ITG Cer-crus-II R R ACC OFC MCC MCC ACC Put OFC Pall MCC ITG ITG MTG Cer-crus-I Cer-crus-II MTG Cer-crus-I ACC Thal MTG Ling Pall OFC Cer-crus-I ITG Cer-crus-II Cer-lobule-VIII ACC Thal Put MTG Pall Ling OFC Cer-crus-I PHG ITG Cer-lobule-VI 11

12 3 rd Nordic MS-Symposium Understanding progressive MS MEASURING PROGRESSIVE MS SESSION II Neuropsychological profiles in MS Adjunct Professor Päivi Hämäläinen, Neurological Rehabilitation Centre, Masku, Finland Päivi Hämäläinen reviewed key aspects of neuropsychological problems in MS before examining ways to treat cognitive impairment. MS is related to both temporary and permanent cognitive problems. Temporary deficits are typically due to symptoms in mood, relapses and fatigue, while permanent deficits are related to changes in the CNS. Around 40% of MS patients are estimated to be cognitively intact, while 40% have relatively mild deficits and around 20% more severe problems. The most vulnerable areas in the 60% experiencing problems seem to be memory and learning, processing speed, attention and executive functions. Note, however, that the cognitive profile in MS is highly individual. One typical feature of cognitive profile in MS is cognitive fatigue. Fatigue may be provoked with heat exposure. For example, a study on the effects of heat stress showed that a significant increase in core body temperature is associated with a mild yet reversible worsening of cognitive function, while visual vigilance performance seems almost unaffected (Hämäläinen P et al. Mult Scler 2012; 18: ). Neuropsychiatric and behavioural problems Neuropsychiatric and behavioural problems in MS are not as well characterised as cognitive impairments. Nevertheless, a systematic data search and meta-analysis of studies on patients with MS or other diseases and healthy controls suggests that patients with MS only report more behavioural symptoms Question: Have you observed problems with your memory, attention or other cognitive functions? no No immediate further steps No problems Figure 1. A model to approach cognitive problems in clinical practice (Päivi Hämäläinen 2015). yes Self/informant report (MSNQ, PDQ, NPI etc) Cognitive problems Neuropsychological assessment (several possible batteries: BICAMS, BRBNT, etc.) Significant findings Further steps: rehabilitation (aggression, apathy, euphoria, lack of insight) than patients with other diseases or controls (Rosti-Otajärvi E, Hämäläinen P. Mult Scler 2013; 19: 31 45). These subjective symptoms also appear to be more frequent than more objective signs. Predictors of neuropsychological impairments The relationship between disease duration, physical disability and disease course appears to be either weak, modest or unclear. Interestingly, the cognitive reserve (the active use of cognitive resources) seems to afford some protection against impairment (Sumowski JF et al. Mult Scler 2013; 19: ). Natural history In intermediate-length follow-up (1 4 years), defined cognitive decline is a risk factor for further deterioration. Over 4 10 years follow-up, cognitive decline typically progresses and becomes more widespread. In the early stages of MS, almost half of the patients exhibit at least some mild cognitive signs, e.g. processing slowness and slow learning, but they are usually well aware of their deficits. When the disease progresses, executive and behavioural problems may appear and awareness may also be affected. Treatment possibilities Disease-modifying medication may slow down the occurrence and progress of cognitive impairments. A further option is neuropsychological rehabilitation. Results of a meta-analysis of 20 studies showed that cognitive training improves memory span and working memory. When combined with other neuropsychological rehabilitation methods, it also improves attention, immediate verbal memory and delayed memory (Rosti-Otajärvi E et al. Cochrane Database Syst Rev 2014; 11). A randomized, controlled multi-centre study to assess whether the strategy-oriented neuropsychological rehabilitation typically used in Finland is effective concluded that although the method does not improve cognitive performance per se, it reduces perceived cognitive deficits and helps coping with cognitive impairments in MS (Mäntynen A et al. Mult Scler 2014; 20: ). Figure 1 illustrates how the lessons learned could be applied in practice. 12

13 Understanding progressive MS 3 rd Nordic MS-Symposium MEASURING PROGRESSIVE MS SESSION II Optical coherence tomography in progressive MS Dr Sigrid Aune de Rodez Benavent, Multiple Sclerosis Research Group, Oslo University Hospital, Oslo, Norway Ophthalmologist Sigrid Aune de Rodez Benavent described how optical coherence tomography (OCT) works and reviewed its potential role in MS subtyping. MS is traditionally evaluated by repeated MRI scans, but brain atrophy is hard to detect by this method. What s more, detecting the functional changes that precede axonal degeneration is even more problematic. Early detection of atrophy is, however, possible by studying visual pathways (looking through the pupil of patients) using OCT, a technique that measures retinal nerve fiber layer thickness (RNFLT). Briefly, infrared light is transmitted through the pupil via a semi-transparent mirror (Fig. 1). The light hits the retina (A) from which it is back-scattered and reflected to a detector that analyzes its different wavelengths (B). This gives rise to an in vivo optical slice picture of the retinal layers (C) that is comparable to a histopathological slice. The technology has been developed extensively since its introduction in 1991 and today the so-called spectral domain OCT technique is employed. OCT is not only an interesting technology but also a possible clinical tool in MS. Since it deals with a ball-shaped organ that may move, beam alignment is critical. This is especially important in multicentre studies. Hence, a series of consensus criteria has been developed for topics such as signal strength, beam placement, illumination, retinal pathology, etc. Of these, retinal pathology is especially important since systemic diseases affecting the eye may have great impact on OCT findings. Ideally, OCT should be followed by an ophthalmological examination. Relationship between brain retina atrophy and MS subtype Several studies have pointed towards OCT being able to distinguish MS subtypes. An early domain OCT (not as precise as spectral domain OCT) investigation concluded that OCT A. Transmitted light Detector Semitransparent mirror splits light beam Retina same distance as mirror #2 C. Image of the retinal layers Figure 1. The operating principle of optical coherence tomography (modified from Frohman EM et al. Nat Clin Pract Neurol 2008; 4: ). Infrared light 800 nm wavelengths Mirror #2 B. Reflected light Detector Infrared light 800 nm wavelengths Mirror #2 13

14 3 rd Nordic MS-Symposium Understanding progressive MS MEASURING PROGRESSIVE MS SESSION II measurement could correlate with EDSS and suggested that a combination of OCT and MRI was warranted (Albrecht P et al. J Neurol 2007; 254: ). In addition, significant global reductions in RNFLT and macular volume have been observed in the eyes of SPMS patients not previously affected by optic neuritis, but not in PPMS patients (Henderson AP et al. Brain 2008; 131: ). In contrast, Gelfand and colleagues reported that RNFL thinning was nearly identical between progressive MS subtypes (Gelfand JM et al. PLoS One 2012; 69: ). Interestingly, a recent study on axonal loss of retinal neurons in MS did demonstrate a strong tract-specific association between loss of RNFL fiber and MS-related inflammation (Klistorner A et al. Neurology 2014; 82: ). The question of whether or not OCT should be used as a routine clinical tool and surrogate marker of brain atrophy thus remains controversial and opposing views on the matter have recently been presented (Saidha S, Calabresi PA. Mult Scler 2014; 20: , Jenkins TM, Toosy AT. Mult Scler 2014; 20: ). In conclusion, we can state that while OCT is a good diagnostic tool for making a histo-optical snapshot of the retinal layers, further studies are necessary to evaluate if it can reliably differentiate between different MS subtypes. 14

15 Understanding progressive MS 3 rd Nordic MS-Symposium BIOMARKERS SESSION III Understanding progressive MS immunological biomarkers Professor Finn Sellebjerg, Danish Multiple Sclerosis Center, Rigshospitalet, University of Copenhagen, Denmark Finn Sellebjerg briefly reviewed current opinions regarding the different phases of MS before examining several potential biomarkers of the progressive disease stage, two of which performed well in studies. The common view that MS is probably a two-stage disease with the inflammatory relapsing-remitting phase stage followed by a neurodegenerative progressive phase is perhaps too simplistic. One new way of viewing MS status is to look at the progressive disease and see whether the patient has slow progression, or if there is additional evidence of inflammatory disease activity independent of slow progression. Such factors are important to consider when discussing the role of inflammation and immunology in progressive MS. The concept is interesting, but the key question is whether it will hold true. Examining the immunology of MS, which is quite well studied in RRMS, indicates that the disease is initiated in the immune system and that T cells play a crucial role; Th1 cells make IFN gamma, Th17 cells make IL-17 and other inflammatory cytokines, and cytotoxic CD8 T cells migrate into the brain and spinal cord where they induce tissue damage and demyelination. A range of regulatory cells is also on hand to balance these effects. Our own study of systemic inflammation in progressive MS confirmed that one T cell type, known as follicular helper cells, is more active in patients with RRMS and SPMS (Romme Christensen J et al. PLoS One 2013; 8: e57820). Other T cell types, such as pro-inflammatory Th17 cells, were slightly more prevalent in RRMS, but much more so in SPMS and PPMS compared to controls. This finding suggests a pathogenic role of systemic inflammation in progressive MS. Explanations for these differences can be found by looking at RRMS and progressive MS pathology. RRMS patients have focal lesions, but relatively few cortical lesions or diffuse white matter changes, which are very prevalent in patients with primary and secondary progressive MS. Some SPMS patients also display a very organized form of inflammation in the meninges. Conversely, active white matter lesions are more frequent in patients with acute MS and RRMS than in progressive MS. The difference between primary and secondary progression is most readily seen in the cortical demyelinated lesions and in normal-appearing white matter (NAWM) inflammation and tissue damage. Biomarkers of progressive MS One biomarker that has received considerable attention is osteopontin (OPN), a type of secreted connective tissue protein whose function resembles that of a cytokine. OPN is also present in an intracellular form that affects dendritic cells by promoting proinflammatory immune responses. It is nevertheless the secreted form that can be measured. A 2009 study on the effects of natalizumab on inflammatory mediators in MS showed that patients with active MS about to start treatment had increased OPN concentrations compared to controls (Khademi M et al. Eur J Neurol 2009; 16: ). After 12 months treatment, however, OPN levels had essentially normalized (Fig. 1). As well as responding to the treatment effect of natalizumab, OPN increases in CSF during relapses of MS and correlates with the concentration of tau as a biomarker of neuroaxonal damage. It does not correlate, however, with cell count in CSF or with the expression of OPN mrna in CSF cells. OPN thus ng/ml 1, OND OPN in cell-free CSF P< P< RRMS (Baseline) OND, other neurological disease RRMS (12 months) Figure 1. In active MS patients, osteopontin (OPN) concentrations in CSF decreased and essentially normalized following 12 months treatment with natalizumab (modified from Khademi M et al. Eur J Neurol 2009; 16: ). 15

16 3 rd Nordic MS-Symposium Understanding progressive MS BIOMARKERS SESSION III CSF osteopontin (ng/ml) seems to derive from brain and spinal cord tissue rather than from cells in the CSF. A later study in a broader panel of MS patients showed that SPMS and PPMS patients, as well as relapse patients, had increased concentrations of OPN in CSF (Romme Christensen J et al. Mult Scler 2013; 19: ). It is also known that OPN correlates with neurofilament light-chain (NF-L) concentrations in progressive MS patients. Overall, therefore, the inflammation measured by OPN appears to be related to tissue damage. The same study also investigated other biomarkers, including matrix metalloproteinase-9 (MMP-9) and the chemokine CXCL13. Neither provided the same amount of useful information as OPN. Baseline p= weeks natalizumab Figure 2. CSF OPN decreased significantly from baseline to week 60 in both PPMS and SPMS patients receiving natalizumab (modified from Romme Christensen J et al. Neurology 2014; 82: ). Neurofilament (NF) is increasingly used as a measure of tissue damage in MS, especially in Sweden where it is now used in clinical practice. NF-L, a readily measurable component of NF, has been analyzed in many studies. PPMS SPMS NIND mean +/- 95% CI One such study on immunosuppressive therapy included 35 patients with progressive MS. Most were untreated but about one-third had received immunomodulating therapy. Five were treated with rituximab and 30 with mitoxantrone (Axelsson M et al. Mult. Scler. 2014; 20: 43 50). A clear increase in NF-L levels was seen in the pre-treatment group compared to controls. Levels decreased significantly compared to baseline after months, but were still somewhat higher than the control group. Natalizumab treatment of progressive MS The NAPMS study was an open-label phase II study where 24 patients with progressive MS received natalizumab for 60 weeks. Response to treatment was assessed in CSF and with MRI. The primary endpoint was change in CSF OPN from baseline to week 60. CSF OPN decreased by 65 ng/ml (p=0.0004) from baseline to week 60, and this effect was seen in both PPMS and SPMS patient groups (Fig. 2). Furthermore, decreases in other CSF biomarkers of inflammation, axonal damage, and demyelination were noted. In addition, magnetization transfer ratio (MTR) increased in both cortical grey and NAWM, and correlated with decreases in CSF NF-L (Romme Christensen J et al. Neurology 2014; 82: ). Overall, the study provided evidence that natalizumab reduces biomarkers of intrathecal inflammation in patients with progressive MS. Interestingly, the COMTIMS study to examine whether monthly methylprednisolone pulse treatment also impacts disease inflammation in progressive MS failed to show changes in CSF OPN levels (Ratzer R, submitted). NF-L results were also disappointing. MRI data were, however, more promising. Although the first 12 weeks saw no change in T2 lesion volumes, the following 48 weeks demonstrated some decrease. Clear increases in MTRs were also noted. Conclusions Our understanding of progressive MS immunological biomarkers continues to improve. Intrathecal immune activation can be detected by pathology and by biomarkers. Of the wide panel available, OPN performed well, especially in the natalizumab study. At present, NF-L is a good candidate for a responsive biomarker related to the true progressive disease course, but further evidence is needed if it is to secure this role. 16

17 Understanding progressive MS 3 rd Nordic MS-Symposium BIOMARKERS SESSION III Young neurologists session: Adipokines in multiple sclerosis Sanna Hagman, MSc, PhD, Neuroimmunolgy Unit, University of Tampere, Finland Sanna Hagman summarized a number of the immune functions of adipose tissue before focusing on the role of adipokines in MS. The etiology of MS is multi-factorial, displaying both genetic and environmental factors. Many risk factors are known, such as infections, low levels of vitamin D, smoking, stress and female gender (Ramagopalan SV et al. Lancet Neurol 2010; 9: , Hedstrom AK et al. Mult Scler 2012; 18: ). Obesity, especially from childhood until young adulthood, is one of the more recent risk factors to be recognized. However, the exact factors that link obesity to MS remain unknown. Adipose tissue Adipose tissue is today recognized as an endocrinal organ secreting multiple proteins that also modulate inflammation and immunity (Exley MA et al. J Endocrinol 2014; 223: R41 8). Furthermore, the structure of white adipose tissue in the normal-weight person differs from that in the obese individual. In adipose tissue of lean subjects, the metabolic and immune responses are in homeostasis, which results in an anti-inflammatory environment. In the obese state (adipose tissue of the obese subjects), the metabolic and immune responses are deregulated, leading to increased release of fatty acids, hormones and proinflammatory molecules associated with several disorders. In the obese state, adipose tissue is characterized by presence of M2 macrophages that produce TNF-α and IL-6, as well as increase of CD8 cells and B-cells, but less regulatory T cells. The overall result is that obesity leads to chronic low-grade inflammation that may be involved in the development of MS, and also affect the clinical progress of the disease. Adipokines and their role in disease The pro-inflammatory environment and dysfunction in the immune and metabolic responses that characterize obese adipose tissue induce the secretion of proteins known as adipokines (Versini M et al. Autoimmun Rev 2014; 13: ). Adipokines have several functions, including causing immune cells to promote inflammation. Adipsin (complement factor D), one member of the adipokines, is a serine protease in the alternative pathway of complement activation. The role of adipokines in MS has been reported in a limited number of studies; their effect seems to increase serum levels of leptin, resistin and visfatin, while levels of adiponectin appear to decrease (Emamgholipour S et al. PLoS One 2013; 8: e76555). Leptin levels correlate negatively with the number of regulatory T cells (Matarese G et al. Proc Natl Acad Sci U. S. A. 2005; 102: ), but no association between adipokines and disease progression has been reported. The overall situation remains unclear, however. To explore the role of adipokines in MS, especially their association to neurological worsening and disease activity, 77 patients (including RRMS, SPMS, PPMS and CIS) were studied neurologically and by MRI from baseline and anually up to two years (Natarajan R et al, submitted). Blood samples were also collected for adipokine analysis. The levels of leptin, adiponectin, resistin and adipsin in plasma were analyzed using enzymelinked immunoassay (ELISA). All adipokines remained stable, but levels of adipsin were significantly lower in RRMS and CIS patients compared to PPMS groups throughout the follow-up period. Furthermore, adipsin levels correlated with EDSS score and pre-study disease activity in RRMS, as well as with volumes of T1 and FLAIR lesions. Further work revealed that resistin correlated with T1 and FLAIR lesions in RRMS, although no correlations were detected between resistin and clinical parameters. Results of this study suggest a possible role of adipsin in the pathogenesis and severity of MS. The involvement of adipokines in the regulation of immune responses in MS also merits further study. 17

18 3 rd Nordic MS-Symposium Understanding progressive MS BIOMARKERS SESSION III Young neurologists session: CSF prognostic biomarkers in optic neuritis Dr Signe Modvig, Glostrup Hospital, University of Copenhagen, Denmark Signe Modvig presented data on the roles of cerebrospinal fluid biomarkers as predictors of long-term prognosis and highlighted two that show promise in the clinical setting. Biomarker studies of long-term prognosis in CIS patients are scarce. Nevertheless, a number of CSF biomarkers have shown potential for MS conversion, including the chemokine CXCL13 and neurofilament light and heavy chain (NF-L, NF-H). White matter lesion (WML) load at time of CIS is modestly correlated to long-term disability 14 years later (Fisniku LK et al. Brain 2008; 131: ). Biomarkers of tissue damage also show promise in predicting long-term disability in RRMS patients with varying disease duration at time of sampling. For example, high NF-L levels predict shorter time to secondary progression and disability (Salzer J et al. Mult Scler 2010; 16: , Norgren N et al. Neurology 2004; 63: ). We attempted to answer the question of whether long-term prognosis can be predicted at time of onset of the first demyelinating event using optic neuritis as a model for MS relapse (Modvig S et al. Mult Scler 2015, Epub ahead of print). Specific factors examined were risk of and time to MS conversion, physical disability, cognitive function, and visual acuity. The retrospective study comprised 86 patients with optic neuritis as first demyelinating event. At baseline, patients had an MRI ( 2 demyelinating WMLs was defined as abnormal) and a lum- MS-free survival probability ,000 CHI3L1 cut-off 147 ng/ml, PPV 86.7% 0 1 WML + low CHI3L1: MS risk 20% 0 1 WML + high CHI3L1: MS risk 43% 3,000 5,000 7,000 2 WML + low CHI3L1: MS risk 59% 2 WML + high CHI3L1: MS risk 90% Figure 1. Adding the novel biomarker CHI3L1 to MRI had a strong positive effect in predicting 10-year MS risk (modified from Modvig S et al. Mult Scler 2015, Epub ahead of print). bar puncture analysis. A CSF analysis of biomarkers of cellular inflammation in the CNS included CXCL13, CXL10 and matrix metalloproteinase-9, all closely associated with optic neuritis. Biomarkers of inflammation and tissue remodeling (chitinase 3-like 1 [CHI3L1], osteopontin) and tissue damage (NF-L, myelin basic protein) were also measured. Mean follow-up time was 14 years. MRI and CHI3L1 predict ten-year MS risk A multivariate regression analysis with time to clinically definite MS after optic neuritis as outcome showed that 46 patients (53%) developed MS during a median follow-up time of 26 months. Of the established MS risk biomarkers, MRI was by far the best predictor with a hazard ratio of 3.5, while CSF leukocyte count was next best with 1.3. A new regression analysis of these two plus the novel biomarkers revealed MRI, CHI3L1 and age to be the best combination of predictive markers. Furthermore, adding CHI3L1 to MRI had a strong positive effect in predicting MS risk; with less than two demyelinating lesions and CHI3L1 levels below a 147 ng/ml cut-off, the positive predictive value for ten-year risk was 86.7% (Fig. 1). Long-term disability outcome data, adjusted for age and time to follow-up, showed that NF-L was the only novel biomarker that predicted MSSS score (p= ). It also predicted visual acuity and the nine-hole peg test, and a trend for predicting the Paced Auditory Serial Addition Test (PASAT) was observed. Interestingly, CHI3L1 predicted cognitive decline in MS assessed with PASAT. With the same cut-off as applied in the MS risk analysis, its positive predictive value was 70 %. Conclusions The role of CHI3L1 in MS is still unresolved, but a number of possible roles can be suggested from other conditions. It might be involved in astrogliosis tissue remodeling, for example, or play a role in inflammation. Biomarkers of early tissue damage and remodeling are thus promising predictors of long-term MS prognosis after optic neuritis as first demyelinating event. CHI3L1 and NF-L in particular show clinical potential, but the cut-off values need to be validated in larger cohorts. 18

19 Understanding progressive MS 3 rd Nordic MS-Symposium MONITORING MS SESSION IV Can we delay the onset of progressive MS? Helen Tedeholm, MSc, PhD, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Sweden First-generation immunomodulating drugs seem to reduce the risk of secondary progression in MS. Helen Tedeholm reviewed evidence for this effect and looked briefly at how prediction scores may be used in future studies. Contemporary patients given first-generation disease modifying drugs (DMDs) were approximately 60% less likely to experience SP. Further analyses suggested that this effect was at least partly due to long-term immunomodulating therapy. The definition disease progression should be reserved for patients with truly progressing disease as opposed to worsening from a relapse. Worsening is recommended for patients whose disease is advancing for any reason. Several randomized studies on the first-generation immunomodulators used since the early 1990s have demonstrated decreased relapse rates and delayed worsening of disease, but no significant impact on the progressive course. Whether such treatment can delay the transition to secondary progression (SP) and, if so, how it can demonstrated, are issues that require addressing. Long-term treatment effects have been studied in a variety of trial formats. Propensity score-adjusted survival curves from a cohort of 1,504 IFN-beta-treated RRMS patients followed for up to 7 years showed that treatment slowed progression (Trojano M et al. Ann Neurol 2007; 61: 300 6). However, another study of RRMS patients treated with IFN-beta (n=868) compared with untreated contemporary controls (n=829) and historical controls (n=959) showed that IFN-beta was not associated with a reduction in the progression of disability (Shirani A et al. JAMA 2012; 308: ). Swedish MS Register The Swedish MS Register, now including more than 15,000 patients, affords a number of study opportunities. In one study from 2013, time to secondary progression in RRMS patients treated with IFN-beta and glatiramer acetate (n=730) were compared with untreated historical controls (n=186) (Tedeholm H et al. Mult Scler 2013; 19: ). Historical patient materials were collected during the period in the Gothenburg Incidence Cohort (GIC). Demographic and clinical predictors were used as tools to adjust for imbalances between treated patients and historical controls. Significant differences were seen in all subgroups of severity. Continuous prediction of secondary progression A novel approach to predicting SP in the individual course of MS also involved RRMS patients from GIC with a second attack before progression or censoring (n=157) (Skoog B et al. Mult Scler Relat Disord 2014; 3: ). Predictors from all distinct attacks (n=749) during the RRMS phase were used in a Poisson regression analysis. Independent predictors of the current risk of SP were clinical characteristics of the most recent attack, time since the most recent attack, and current age. Figure 1 shows that the risk of transition to SPMS displayed a maximum at around the age of 30. This estimate, including the age dependency and the 3 independent variables, is termed the prediction score. A web-based tool with further details of prediction scores is available at Incidence of SP per patient year Current age (years) (95% CI) Figure 1. Continuous prediction of secondary progression in the individual course of MS. The risk of transition to SPMS showed a maximum around 30 years of age (modified from Skoog B et al. Mult Scler Relat Disord 2014; 3: ). 19

20 3 rd Nordic MS-Symposium Understanding progressive MS MONITORING MS SESSION IV Trials, tribulations and solutions in progressive multiple sclerosis Jeremy Chataway MD, PhD, National Hospital for Neurology and Neurosurgery, University College London Hospital NHS Foundation Trust; University College London, UK The history of MS progression trials highlights the need for much greater consideration to be given to drug selection and study design. Jeremy Chataway cited several historical examples before illustrating a number ways to improve both. Since a phase III trial may cost around $100 million, trial design and efficiency clearly need to be optimised as much as possible. Can we do them faster and can we learn more from previous trials as to the key issues to address? In progressive MS, it is clear that patients want a drug that will halt disease progress and ideally improve their condition, but stopping or slowing the disease is the initial priority. Firstclass drugs, good outcome measures and large powerful trials will go a long way to achieving this goal. There are certainly enough patients. Over one million people have progressive MS globally but probably less than 1% enter trials, possibly due to regulatory barriers being too high. Today s situation with progressive MS is somewhat similar to that of RRMS 20 years ago. Significant achievements have been made in the latter area, particularly over the last five years, and drugs of increasing potency are now emerging. Examining key success factors in this journey should thus help repeat it for the progressive disease stage. A phase II trial for natalizumab (Tysabri ) (O Connor P et al. Mult Scler 2005; 11: ) illustrates how T2 lesion metrics (with gadolinium enhancement) became the key interim marker in developing drugs to take through to Phase III in RRMS. Clearly, the more tightly associated the marker is to disease progression, the fewer subjects are needed in the trial. A good interim marker in progressive MS is essential to make progress. Finding drugs for progressive MS To identify the molecules that are going to stand a chance of actually working in phase III, it is vital to systematically review a broad range of data; biological studies, animal models and molecular analyses. One group in Edinburgh has systematically reviewed the human literature, looking through about 30,000 reports of any drug tried in MS, even in very small studies and particularly if there was any crossover with other degenerative diseases. This could highlight drugs that should be taken into phase II (McLeod M et al. PLoS One, submitted). One such example is riluzole, the only motor neuron disease drug that has so far been licensed: 16 progressive MS patients were studied one year before treatment, followed by 50 mg riluzole for one year. The primary outcome, defined as change in cervical spinal cord cross-sectional area, showed a reduction from -2% (year 1) to -0.2% (year 2) (Killestein J et al. J Neurol Sci 2005; 233: 113 5). Phase III trials in progressive MS Planners of phase III trials in progressive MS can learn a great deal from oncology trials. These have enjoyed great success, largely due to careful consideration about how to carry out the trials efficiently and how to make the best use of the data. The classic phase III cancer trial standard is progression-free survival in MS, we want to attain the equivalent, i.e. disability progression-free survival. Reviewing the early years of MS progression trials, starting about 25 years ago, also reveals valuable information (Ontaneda D et al. 2015; 14: ). Three years appears to be the right duration to demonstrate an effect on disability. Furthermore, we need to enrol truly progressing patients into trials, not inflammatory subjects likely to relapse. A mean age of about 50 is likely, for example, as at 30, subjects have probably not established progressing disease. The early 1990s witnessed the cyclophosphamide and ciclosporine trials, and their termination due to lack of efficacy and tolerability problems. Later on came the beta-ifn studies, with their largely neutral results and, more recently, the CUPID trial using artificial cannabinoids, which was negative. In addition, the fingolimod phase III trial in PPMS (INFORMS) ended this year having not met its primary endpoint. This lack of success may be due to several factors, including lack of sufficient biological understanding, poor drug choice, absence of phase II, and too short a trial duration. Ways to move forward Good phase II trials are extremely important, since they help de-risk the whole phase III process, as the alemtuzumab story 20

21 Understanding progressive MS 3 rd Nordic MS-Symposium MONITORING MS SESSION IV demonstrates. This drug, proven potent in RRMS, was assessed in a small SPMS group but with negative results and therefore not pursued further in progressive MS studies. This is in contrast to the MBP experience. Other ways of moving forward are also available, including factorial designs and multi-arm, multi-stage trials. Factorial trials offer the opportunity to try drug combinations and can be convincing, but they function best with at least one drug that has a proven record, which is not the case in progressive MS today. Seamless multi-arm trials (e.g. drop the looser also have their attractions, since they may avoid stopping a trial at phase II and trying to start it up again for phase III, which is demanding both financially and in terms of regulatory requirements. Patients (%) Placebo Statin The simvastatin trial (MS-STAT) MS-STAT was a randomized, placebo-controlled phase II trial examining the effect of high-dose simvastatin on brain atrophy and disability in SPMS. Patients, aged years, received either 80 mg of simvastatin or placebo with the annualized rate of whole-brain atrophy measured from serial volumetric MRI as the primary outcome (Chataway J et al. Lancet 2014; 383: ). Whole-brain atrophy is regarded as good enough for a phase II trial; it can be measured accurately, it begins early, and it seems to persist throughout the entire disease duration. Mean age of the 140 patients randomized was about 50 and all were judged to have truly progressing SPMS. Simvastatin was selected as trial drug since, in addition to lowering cholesterol, it displays multiple biological effects, particularly on endothelial function, that could be relevant in MS. Change WBV (%/year) Mean 0 12 months Individual values months 0 25 months Figure 1. In the MS-STAT trial, simvastatin reduced whole-brain volume (WBV) change by nearly half compared to placebo in SPMS patients (modified from Chataway J et al. Lancet 2014; 383: ). Figure 2. Change in EDSS score over 24 months suggests that 80 mg simvastatin has a positive effect on disability in SPMS patients (modified from Chataway J et al. Lancet 2014; 383: ). Primary outcome data showed that the brain boundary shift integral (BBSI) change in whole brain volume (%/year) was 0.589% with placebo, while simvastatin reduced this figure by nearly half to 0.298%. Figure 1 shows individual data. Although simvastatin did not work on everyone, it did have a significant effect at group level in reducing atrophy rate. Change in EDSS score from start to 24 months also suggested a positive effect on disability (Fig. 2). Simvastatin thus appears to be a good candidate for progressing to phase III. The main marker, atrophy, will also be refined over time to encompass grey and white matter, as well as other CSF biological markers. This trial may thus represent a good template for how to approach a phase II investigation. Among the newer phase II trials, the MS-SMART trial has just started in the UK ( This multi-armed trial will test three drugs (riluzole, amiloride and fluoxetine) in 440 patients with SPMS. MRI atrophy will be measured over two years. Interestingly, around 2,000 individuals have expressed interest in participating, which illustrates how keen people are to enrol in trials dealing with progressive MS. Conclusions Great efforts should be made in ensuring that the best drugs to investigate are selected and that they are assessed in well- designed phase II trials. Phase III cohorts should also have the same characteristics as phase II. Finally, plenty of patients are willing to participate. With efficient multiple-arm designs, trials should not have to take as long as they now do. 21

22 3 rd Nordic MS-Symposium Understanding progressive MS MONITORING MS SESSION IV Management of progressive MS Professor Sten Fredrikson, Dept. of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden Sten Fredrikson reviewed general aspects of primary and secondary progression, including whether they should be managed in similar ways, before outlining pharmacological possibilities for treating key symptoms. The last 15 or 20 years have generally been an era of optimism for RRMS patients, but this feeling has not been reflected for those with progressive disease, as the following quotation demonstrates: The prospects of patients with progressive MS are devastating. Patients know that their symptoms will slowly and relentlessly worsen, that their lives will become increasingly restricted by disability, and that no treatment is available to slow down this process (Koch MW et al. Nat Rev Neurol 2013; 9: ). Patients with progressive MS have clearly increased mortality and currently available disease-modifying therapies are not helpful, despite some studies carried out in the mid 90s showing promise. Methylprednisolone, investigated in chronic progressive MS (Cazzato G et al. Eur Neurol 1995; 35: 193 8) and in SPMS (Goodkin DE et al, Neurology 1998; 51: ) appeared to have positive effects, for example, and perhaps merits follow up. Previous work also suggests that primary and secondary progressive patients should be treated in the same way. Both groups start displaying symptoms at around age 40 and both follow a similar evolution pathway. Urgency and frequency Test for UTI Measure PVR <100 mls Teach CISC Treat with antimuscarinics No Better? No Continent Yes Figure 1. Management algorithm for MS patients presenting with urinary tract symptoms (modified from Fowler CJ et al. Postgrad Med J 2009; 85: 552 9). CISC, clean intermittent selfcatheterisation PVR, post-void residual volume UTI, urinary tract infection Regarding diagnostic criteria for MS, it can be noted that the latest version of the McDonald criteria (Polman CH et al. Ann Neurol 2011: 69: ) may not represent an actual improvement for PPMS patients since CSF investigation, obligatory in the earlier version, is now optional. To avoid including patients with myelopathy due other causes, an active CSF examination is highly recommended. Note also the lack of an established consensus about how to measure progression on MRI. Symptoms and scales When discussing the management of progressive MS, it is now more common to talk about symptoms that affect physical activity, rather than optic neuritis, numbness or the usual relapse symptoms. Symptoms of a more invisible character, e.g. pain and fatigue, are also included in today s list, which can be considered to comprise the following: spasticity, bladder, cognition, fatigue, pain, depression, sexual, bowel and ataxia. This approach better reflects how patients feel and highlights the issues for clinicians to address and improve. One inherent problem in assessing progression is the pitfalls of EDSS. However, methods for measuring other symptoms in an easy and objective way are not really feasible for daily practice. Some subscales are perhaps not even clinically meaningful. In addition, evidence-based medicine is quite weak for symptomatic treatment in MS. Treatment options and possibilities One key question is whether we should try to separate the symptoms of progressive MS, e.g. cognitive problems, depression and fatigue, and treat only one of them, or adopt an en bloc approach. As is generally recognized, some treatments may cause new symptoms. Treating depression can lead to sexual disturbances, for instance. In the clinical context of the disease, it should also be noted that issues other than MS can cause progression. Therefore, the spinal MRI should be checked to rule out other causes of myelopathy (e.g. spondylosis, metastasis, etc.) and screening with simple blood tests should be carried out when fatigue is observed. 22