Thursday, 22 June 2017

Myelin Autoimmunity in T cells. Time to say schtop!. MS lesions are EBV killing zones

van Nierop GP, van Luijn MM, Michels SS, Melief MJ, Janssen M, Langerak AW, Ouwendijk WJD, Hintzen RQ, Verjans GMGM. Phenotypic and functional characterization of T cells in white matter lesions of multiple sclerosis patients.  Acta Neuropathol. 2017 doi: 10.1007/s00401-017-1744-4. [Epub ahead of print]

T cells are considered pivotal in the pathology of multiple sclerosis (MS), but their function and antigen specificity are unknown. To unravel the role of T cells in MS pathology, we performed a comprehensive analysis on T cells recovered from paired blood, cerebrospinal fluid (CSF), normal-appearing white matter (NAWM) and white matter lesions (WM L) from 27 MS patients with advanced disease shortly after death. The differentiation status of T cells in these compartments was determined by ex vivo flow cytometry and immunohistochemistry.

T-cell reactivity in short-term T-cell lines (TCL), generated by non-specific stimulation of T cells recovered from the same compartments, was determined by intracellular cytokine flow cytometry. Central memory T cells predominated in CSF and effector memory T cells were enriched in NAWM and WM Lesion. WM Lesion-derived CD8+ T cells represent chronically activated T cells expressing a cytotoxic effector phenotype (CD95L and granzyme B) indicative for local antigenic stimulation (CD137). The same lesions also contained higher CD8+ T-cell frequencies expressing co-inhibitory (TIM3 and PD1) and co-stimulatory (ICOS) T-cell receptors, yet no evidence for T-cell senescence (CD57) was observed.

The oligoclonal T-cell receptor (TCR) repertoire, particularly among CD8+ T cells, correlated between TCL generated from anatomically separated WM Lesions of the same MS patient, but not between paired NAWM and WM Lesion. Whereas no substantial T-cell reactivity was detected towards seven candidate human MS-associated autoantigens (cMSAg), brisk CD8+ T-cell reactivity was detected in multiple WM Lesions-derived TCL towards autologous Epstein-Barr virus (EBV) infected B cells (autoBLCL).

Collectively, the data suggest the involvement of effector memory cytotoxic T cells recognizing antigens expressed by autoBLCL, but not the assayed human cMSAg, in WML of MS patients.

What does this study suggest? 

Advanced Disease is associated with active inflammatory lesions, so maybe not too late for a DMT.

Is it time for the card-carrying  CD4 T cell immunologists to pack up their bags and work on a different condition.

Is it time to say no more CD4, Th17 immunology in lab mice.

There is no autoimmunity to myelin basic protein or myelin oligodendrocyte glycoprotein, Kir 4.1 (potassium channel)

Cells in active lesions recognized Epstein Barr Virus, cells in normal appearing white matter did not.

You don't want your therapeutic drug to increase CD45RO, CCR7- effector memory cells..

The data suggests that CD8 T cells cause the active lesions or are associated with the active lesions and they are killing EBV infected B cells.

How does this fit with the B memory cell idea. It fits perfectly. 
If you get rid of the B memory cells you get rid of the EBV, so nothing to get the CD8 T cells going. It may suggest that blocking CD8 would stop the attack, but it wouldn't remove the problem.

This supports the approach developed by Prof Pender in Oz...
What ever happened to ProfGs hope to be involved with this?

Why MS?

It maybe has something to do with the formation of the B cell follicles creating a steady stream of CNS B cells ripe for attack, if you get follicles in the joint you get arthritis.

However do we find T cell reactivity to EBV because we are looking for reactivity to EBV

Nice study from our mates the Netherlands

Wednesday, 21 June 2017

A NEWsletter for families affected by MS and those who support them.

Digesting Science has sent out the first monthly email newsletter to families affected by MS and those who support them. I'd love to know what you think of our first offering, sent out yesterday. 

We want to update you on project news and tell you about Digesting Science as the kits travel the country (and the world!). We have top tips for families living with MS, written by families living with MS. And we have research news in Plain English.

Reading this blog, I see a lot of comments that suggest most of you are au fait with scientific language and medical jargon. But for those who aren't, reading up about MS research can be confusing and even overwhelming. We really think research news should be accessible for EVERYONE who wants to know more about their condition. And we want to empower people to see beyond the often (shamefully) misleading headlines some media outlets propagate in response to big announcements in the research world. We hope that the Digesting Science newsletter will provide research news that doesn't oversimplify the message, but doesn't obfuscate it with technical words either.

If you'd like to subscribe to the new email, then you can do so here.

And don't forget to let me know what you think of this one!

B cell dependent EAE

Sefia E, Pryce G, Meier UC, Giovannoni G, Baker D. Depletion of CD20 B cells fails to inhibit relapsing mouse experimental autoimmune encephalomyelitis. Mult Scler Relat Disord. 2017 May;14:46-50. doi: 10.1016/j.msard.2017.03.013.

This paper warns about the value of using mice to understand B cell activity in MS. It looks at a few published studies or mouse studies and asks you to think.

If we look in the abstract in the paper below , the work is now done in a B cell- and antibody-dependent mouse model of MS. 

Is this the beginning of the airbrushing to make EAE into a B cell disease, this current paper says stop it simply isn't a B cell disease, it is a T cell disease, where B cells and B cell products can influence the T cell mediated disease.

So what is this B cell dependent disease. It is MP4-induced EAE in C57BL/6 mice. Kuerten S, Pauly R, Rottlaender A, Rodi M, Gruppe TL, Addicks K, Tary-Lehmann M, Lehmann PV. Myelin-reactive antibodies mediate the pathology of MBP-PLP fusion protein MP4-induced EAE.Clin Immunol. 2011;140:54-62. 

This model only develops when you have antigen presenting B cells. First, how representative is this very artificial system. (left) 

The C57BL/6 is amongst the most EAE resistant mouse strain and it was thought to be resistant to myelin basic protein and spinal cord disease until myelin oligodendrocyte glycoprotein came around. MP4 is a synthetic protein of myelin basic protein and water-soluble peptides of proteolipid protein, which are both not expressed on the surface of myelin and so difficult to target for antibodies. (Although antibodies may bind to epitopes outside and inside the myelin). So it was found that a disease resistant strain, could not develop disease with a weak antigen in that strain, unless it has a full complement of antigen presenting cells. 

Nothing has been done to show the issues are really different from any other T cell dependent EAE. If you add myelin antibodies to T cell EAE, this it makes the disease worse, usually, but that does not make it only B cell dependent. The antibodies also appear to be detected after the clinical disease (figure right).

Do we base our ideas on an outer extreme? 

Do we follow it without question, I suspect I can guess how people will treat this (this from one of the guys that gave us epitope spread). I have heard the view from ProfG, enjoy. 

Is this why natalizumab work's in Crohns too?

Of course not....but had you thinking:-)
(P.S. In the gut cells home using alpha4 beta 7 integrin rather than the brain which use alpha 4 beta 1 integrin. natalizumab block alpha4 integrin

MS in the guts

Wunsch M, Jabari S, Voussen B, Enders M, Srinivasan S, Cossais F, Wedel T, Boettner M, Schwarz A, Weyer L, Göcer O, Schroeter M, Maeurer M, Woenckhaus M, Pollok K, Radbruch H, Klotz L, Scholz CJ, Nickel J, Friebe A, Addicks K, Ergün S, Lehmann PV, Kuerten S. The enteric nervous system is a potential autoimmune target in multiple sclerosis. Acta Neuropathol. 2017. doi: 10.1007/s00401-017-1742-6. [Epub ahead of print]

Multiple sclerosis (MS) is a chronic autoimmune disease of the central nervous system (CNS) in young adults that has serious negative socio-economic effects. In addition to symptoms caused by CNS pathology, the majority of MS patients frequently exhibit gastrointestinal dysfunction, which was previously either explained by the presence of spinal cord lesions or not directly linked to the autoimmune etiology of the disease. Here, we studied the enteric nervous system (ENS) in a B cell- and antibody-dependent mouse model of MS by immunohistochemistry and electron microscopy at different stages of the disease. ENS degeneration was evident prior to the development of CNS lesions and the onset of neurological deficits in mice. The pathology was antibody mediated and caused a significant decrease in gastrointestinal motility, which was associated with ENS gliosis and neuronal loss. We identified autoantibodies against four potential target antigens derived from enteric glia and/or neurons by immunoprecipitation and mass spectrometry. Antibodies against three of the target antigens were also present in the plasma of MS patients as confirmed by ELISA. The analysis of human colon resectates provided evidence of gliosis and ENS degeneration in MS patients compared to non-MS controls. For the first time, this study establishes a pathomechanistic link between the well-established autoimmune attack on the CNS and ENS pathology in MS, which might provide a paradigm shift in our current understanding of the immunopathogenesis of the disease with broad diagnostic and therapeutic implications.

The opening line of the abstract gives a different twist usual science rag, it says that MS makes you poor. It gets weirder from there.

First we had the microbiota and the nervous system. 

Did you spot the possible link between the microbiome and autoimmunity after alemtuzumab in our recent paper this week, yes there are hidden gems in there. 

It is still free to download and read if you want click and follow the links.

Now we are being told it is the enteric (gut) nervous system that's a problem. We would agree that with time that there are clearly problems with the gut in mice with EAE, and believe it or not we did a project looking at constipation, so in this case we can definitely say the chicken led to the egg. That the gut problems come after the autoimmunity of the CNS.

However, in this study they imply that the gut autoimmunity comes first. They report gut problems before there is evidence of autoimmunity in the CNS in an animal model.  There was significantly less gut motility.

So should we make some students or MD2 count and weigh mouse poohs. It would not be surprising in mice with neurological EAE that there pooh count will be affected, as they eat and drink less when they are neurologically affected, but being a recipient of quite a few mouse number 2's in my time when holding a mouse, they maintain this function early in the disease course.  

They found antibodies that targeted the gut in mice, which were present in some people with MS and there was some gut pathology with MS. If they had made the suggestion that MS was secondary to autoimmunity in lung tissue would this have been found? 

But how does this disprove the possibility that lesions in the CNS has led to de-innervation of gut pathways and the effect is secondary to this. You are not going to get an answer against this from studying post-mortem MS years after disease onset.

But you are going to get support that there are gut changes in MS

Moser AM, et al. Mucosal biopsy shows immunologic changes of the colon in patients with early MS. Neurology, N2.

Objective: To investigate immune cells of the colonic mucosa and faecal short-chain fatty acids (SCFAs) in treatment-naive patients with a clinically isolated syndrome (CIS) or early relapsing MS.
Methods: In this cross-sectional proof-of-concept study, we obtained mucosal specimens during ileocolonoscopy from 15 untreated patients with CIS/MS and 10 controls. Mucosal immune cells were analyzed by FACS, and gas chromatography-mass spectrometry measurements of stool samples served to determine SCFA.
Results: The number of total dendritic cells (DCs), CD103+ tolerogenic DCs, and CD4+25+127–regulatory T cells (Tregs) was significantly reduced in the distal colon of patients with CIS/MS compared with controls, whereas we found no differences in the proximal colon. The patients' faecal samples also showed a substantially lower content of SCFA and especially lower levels of butyrate and acetate.
Conclusions: Our findings indicate a disturbed homeostasis of colonic DCs and Tregs in patients with MS which could be associated with colonic SCFA depletion. Although not implying causality, these findings confirm parallel abnormalities of the gut in MS and warrant further research if modulation of the colonic SCFA profile or the colonic Treg pool can serve to modify the course of MS.

#NeuroSpeak & #BrainHealth: walking the talk

How competitive is your group when it comes to the health of your brain? #BrainHealth #NeuroSpeak

We have been promoting 'the holistic management of MS' and 'brain health' for sometime now, hoping that the wider MS community will take the message seriously. If you repeat things enough people may start to notice and say, yes I should do this.

Interestingly, I was made aware yesterday of a Novartis funded site ( to educate pwMS about brain health. Has anyone used the site? If yes, how did you find it? 

People with MS who exercise more and have higher self-rated health had lower levels of functional limitations 11 years later. Is this chicken or egg? Did the exercise result in better outcomes or did those pwMS who were doing well simply able to exercise more? Is this observation an association or is it causal? For this we need to do randomised trials or look to animal models and other data to make the case that exercise is actually good for you. It is clear that exercise is more than just a manifestation of being physically able; exercise has biological effects that change the way the brain functions. 

Based on these and other observations exercise should be classified as a DMT (disease-modifying treatment) for MS and that everyone with MS should be enrolled on an ongoing exercise programme of some description. It doesn't matter how disabled you are there is always a form of exercise that you will be able to perform. 

If you don't have MS and are reading this post, for example you may be a HCP, Scientist or Pharma Executive, you should also be doing regular exercise. The data linking regular exercise to a reduced risk of developing dementia, or age-related cognitive impairment, is overwhelming. The problem we face is that as our society gets more sedentary how do we get people to do more exercise? This is a big public health challenge. It is time to formalise our Barts-MS Brain Health Challenge into something more concrete? 

Jodi Haartsen, a MS Nurse Practitioner, from Australia contacted me over 2 years ago about setting up a platform so that Australian MS Healthcare professionals could compete against UK MS HCPs & pwMS. We can now make this happen. How?

Virgin Pulse an organisation that is trying to transform the cultures of the world's leading organisations and improve the health and performance of employees, launched the Global Challenge (formerly known as GCC). Virgin Pulse provides a technology solutions that promote employee engagement and well-being. The next Global Challenge starts 6th September 2017.

I am going to suggest that as many MS Units and Pharma teams take-up the challenge and compete with each other. We are prepared to curate a list of competing centres and groups. If you are prepared to join please register via the Google form below and register at Virgin Pulse.

When we surveyed readers when we raised the challenge, most of you were up to doing it. I hope nothing has changed.

Stuifbergen et al. Selected health behaviors moderate the progression of functional limitations in persons withmultiple sclerosis: Eleven years of annual follow-up. Disabil Health J. 2016 Jan 28. pii: S1936-6574(16)00008-X.

BACKGROUND: Multiple sclerosis (MS), a chronic neurological disease typically diagnosed in young adulthood, presents with a wide variety of symptoms, impairments and functional limitations. Given the chronic, unpredictable and long-term nature of this disease, preserving function is essential.

OBJECTIVE: The purpose of this study was to identify psychosocial and behavioral factors that might influence the trajectory of functional limitation through eleven years of longitudinal follow-up of a sample of persons with MS.

METHODS: Participants (N = 606) completed measures of health behaviors, related constructs and functional limitations annually over eleven years. Longitudinal measures of functional limitations were analyzed using random-effects regression that allows for study of individual differences in the trajectories of a measure. Using the best fitting quadratic growth model, we tested the within and between-person effects of Nutrition, Interpersonal Relationships, Exercise, Stress Management, Health Responsibilities, Spiritual Growth, Self-rated Health and Barriers, controlling for Age, Year since Diagnosis and Year of Dropout, on Functional Limitations in the 11th year.

RESULTS: After adjusting for covariates, higher mean scores for Exercise and Self-rated Health were related to lower levels of Functional Limitations in Year 11. Higher mean scores for Stress Management, Health Responsibilities and Barriers were related to higher levels of Functional Limitations in Year 11. Higher mean Exercise scores and lower mean Health Responsibilities scores were related to slower rates of progression of functional limitations in Year 11.

CONCLUSION: Findings suggest that the highly variable trajectory of functional limitations in MS may be extended and shaped through health behavior strategies.

Tuesday, 20 June 2017

If you want to make a real difference in this world, it's a lot harder than it seems

As I watched Larissa Sansour's short exhibition entitled "In the Future, They Ate From the Finest Porcelain" at the Barbican today, it dawned on me that science, medicine, and new discoveries all create alternative realities. A reality that cannot be predicted precisely by historians or politicians come to that. In essence, the work becomes a historical intervention - a de facto truth of the future, and not the past.

"We are depositing facts in the ground for future archaeologists to evacuate. These facts will confirm the existence of this people we are positing.
So only in the future will people learn that the civilization ate from the finest porcelain?
Yes, only then.
Very few raptures are instantaneous."

In practice I have often used the PRISMS-15 study (see below for the abstract, 15y outcome of the original RRMS trial in PwMS receiving interferon beta-1a, 44ug or 22ug, three times a week compared to placebo) as evidence that higher dose exposure and longer time on treatment, improves clinical outcomes. The proportion of individuals with EDSS≽4 in the high dose group (31.8%) was almost half that in the low dose group (60.7%), while the proportion with EDSS≽6 was a quarter in the high dose (13.9%) of that seen in the low dose group (52.1%). Around half of the low dose group (52.1%) converted to secondary progressive MS compared to a fifth in the high dose group (20.8%). The 15 year analysis also revealed that change in EDSS from start of the trial to 24 months and medication possession ratio (calculated as 100 x time [in days] on treatment from the start to the 15y visit) predicted secondary progressive MS conversion, suggesting that early treatment and adherence to treatment were important factors in obtaining good clinical outcomes. 

This real-world data is very informative; information that would not have been known back in 1998 when the original study was published. My hope is that more clinicians and PwMS adopt these principles when managing MS rather than living in the past.

J Neurol Neurosurg Psychiatry. 2015 Nov;86(11):1202-7. doi: 10.1136/jnnp-2014-310024. Epub 2015 Sep 15.

Factors influencing long-term outcomes in relapsing-remitting multiple sclerosis: PRISMS-15.

Kappos L, Kuhle J, Multanen J, Kremenchutzky M, Verdun di Cantogno E, Cornelisse P, Lehr L, Casset-Semanaz F, Issard D, Uitdehaag BM.



An exploratory study of the relationship between cumulative exposure to subcutaneous (sc) interferon (IFN) β-1a treatment and other possible prognostic factors with long-term clinical outcomes in relapsing-remitting multiple sclerosis (RRMS).


Patients in the original PRISMS study were invited to a single follow-up visit 15 years after initial randomisation (PRISMS-15). Outcomes over 15 years were compared in the lowest and highest quartile of the cumulative sc IFN β-1a dose groups, and according to total time receiving sc IFN β-1a as a continuous variable per 5 years of treatment. Potential prognostic factors for outcomes were analysed.


Of 560 patients randomised in PRISMS, 291 returned for PRISMS-15 and 290 (51.8%) were analysed. Higher cumulative dose exposure and longer treatment time appeared to be associated with better outcomes on: annualised relapse rate, number of relapses, time to Expanded Disability Status Scale (EDSS) progression, change in EDSS, proportions of patients with EDSS ≥ 4 or ≥ 6, ≤ 5 relapses and EDSS <4 or <6, and time to conversion to secondary-progressive MS (SPMS). Higher dose exposure was associated with lower proportions of patients with EDSS progression and conversion to SPMS, and longer time on treatment with lower risk of first relapse. Change in EDSS from baseline to 24 months was a strong predictor of evaluated clinical outcomes over 15 years.


These findings suggest that higher cumulative exposure to sc IFN β-1a may be associated with better clinical outcomes, and early change in EDSS score may have prognostic value, over many years, in RRMS.

Monday, 19 June 2017

#ResearchSpeak: derisking alemtuzumab

Making alemtuzumab, or the son of alemtuzumab, safer; is it too late? #MSBlog #ResearchSpeak

It has been ~5 years since I approached Genzyme with a hypothesis to derisk alemtuzumab. I first posted on the topic of derisking alemtuzumab on the blog in 2014. I discussed derisking infusion reactions and secondary autoimmunity.
To reiterate my position is that once oral cladribine and ocrelizumab are launched most thinking pwMS and neurologists will have a hard time justifying taking the risks of alemtuzumab. Why? You get similar efficacy from ocrelizumab, a maintenance treatment, and if you want to go the PIRT (pulsed immune reconstitution therapy; previously referred to as an induction therapy) route cladribine is much safer than alemtuzumab. With cladribine you get no secondary autoimmunity, no infusion reactions and much fewer infections because cladribine doesn't take-out innate immunity or deplete T-cells to the same degree as alemtuzumab. Cladribine also has the advantage of being oral and its monitoring requirements are so much less arduous. The bottom line is would you go into a randomised trial of alemtuzumab vs. alemtuzumab plus a second agent to try and prevent secondary autoimmunity or would you choose ocrelizumab or oral cladribine? I suspect you would choose one of the latter two options. This means we will have lost equipoise and our proposed trial(s) will be unethical.

The immune system has many mechanisms in place to prevent autoimmunity. When you learn how the immune system works it is really quite surprising that autoimmunity is so uncommon. What the immunologists tell us is that there must be a series of underlying biological processes that are causing secondary autoimmunity and if we can work out what these are we can intervene and prevent this complication. This is what the Professor Alasdair Coles, and Dr Joanne Jones, have been trying to do in Cambridge. They think that because the immune system reboots itself from peripheral memory cells it is more likely to result in an aberrant autoimmune responses. They have done a trial to encourage rebooting of the immune system using more naïve cells from the thymus. They have treated MSers after alemtuzumab with a hormone called, Palifermin, that stimulates the thymus to produce more naïve T-cells. The study is called the Cam-Thy study.

We have a different take on what is responsible for the secondary autoimmunity and wanted to test a different strategy; we hypothesised several years ago that it was due to B-cell hyperproliferation. Based on our hypothesis Palifermin should exacerbate the problem; increasing reconstitution with naive cells without regulation will increase secondary autoimmunity.

Importantly, when you compare cladribine, another immune system rebooter, with alemtuzumab you can’t help but notice that the B-cell reconstitution profiles are very different. With alemtuzumab they come back very quickly and overshoot their baseline values. We have hypothesised that if you changed the profile of the B cell reconstitution with a small dose of the B cell depleting antibody rituximab you may be able to prevent this secondary autoimmunity. We are really talking about a very small dose of rituximab, i.e. 50-100mg, just enough to allow to delay B cell reconstitution by 4-6 months. This is the concept trial that Genzyme rejected several years ago.

In response to the challenge above the Mouse Doctor and DrK have analysed the alemtuzumab reconstitution data in more detail and the analysis strongly supports this hypothesis. Where to from here? I think we could still do a proof-of-concept trial, but focusing on anti-drug antibodies, i.e. anti-alemtuzumab antibodies as the readout. Alemtuzumab is a humanised antibody and the incidence of anti-drug antibodies should be very low. Alemtuzumab appears to break immune tolerance and the mechanisms that underlie anti-drug antibodies may be the same as  those that underlie secondary autoimmunity. 

Baker et al. Interpreting Lymphocyte Reconstitution Data From the Pivotal Phase 3 Trials of Alemtuzumab. JAMA Neurol. 2017 Jun 12. doi: 10.1001/jamaneurol.2017.0676.

IMPORTANCE: Alemtuzumab, a CD52-depleting monoclonal antibody, effectively inhibits relapsing multiple sclerosis (MS) but is associated with a high incidence of secondary B-cell autoimmunities that limit use. These effects may be avoided through control of B-cell hyperproliferation.

OBJECTIVE: To investigate whether the data describing the effect of alemtuzumab on lymphocyte subsets collected during the phase 3 trial program reveal mechanisms explaining efficacy and the risk for secondary autoimmunity with treatment of MS.

DESIGN, SETTING, AND PARTICIPANTS: Lymphocyte reconstitution data from regulatory submissions of the pivotal Comparison of Alemtuzumab and Rebif Efficacy in Multiple Sclerosis I and II (CARE-MS I and II) trials were obtained from the European Medicines Agency via Freedom of Information requests. Data used in this study were reported from June 22 to October 12, 2016.

MAIN OUTCOMES AND MEASURES: Tabulated data from T- and B-lymphocyte subset analysis and antidrug antibody responses were extracted from the supplied documents.

RESULTS: Alemtuzumab depleted CD4+ T cells by more than 95%, including regulatory cells (-80%) and CD8+ T cells (>80% depletion), which remained well below reference levels throughout the trials. However, although CD19+ B cells were initially also depleted (>85%), marked (180% increase) hyperrepopulation of immature B cells occurred with conversion to mature B cells over time. These lymphocyte kinetics were associated with rapid development of alemtuzumab-binding and -neutralizing antibodies and subsequent occurrence of secondary B-cell autoimmunity. Hyperrepopulation of B cells masked a marked, long-term depletion of CD19+ memory B cells that may underpin efficacy in MS.

CONCLUSIONS AND RELEVANCE: Although blockade of memory T and B cells may limit MS, rapid CD19+ B-cell subset repopulation in the absence of effective T-cell regulation has implications for the safety and efficacy of alemtuzumab. Controlling B-cell proliferation until T-cell regulation recovers may limit secondary autoimmunity, which does not occur with other B-cell-depleting agents. 

CoI: multiple

Sunday, 18 June 2017

#ClinicSpeak & #ThinkHand: ability to cut your own toenails correlates with EDSS

Why do we continue to treat hand function as a secondary outcome in clinical trials? #ClinicSpeak #ToeArt #ThinkHand

When  we launched our #ThinkHand campaign last year one of the hand functions that pwMS wanted to preserve was the ability to cut their toenails. This hand function item is pretty obvious. Since then I have started inspecting the state of my patients toenails in clinic and noticed that poor toenail maintenance was clearly linked to disability (EDSS) and deprivation or social isolation. In other words if you can't cut your own toenails and you don't have a partner or family member to do your toenails get neglected. I then did a survey on this topic and of 45 respondents with analysable results there was a clear correlation between EDSS and the ability to cut toenails, which was highly significant.

DfSum SqMean SqF valuePr(>F)
Model177.86877.86823.021< 0.0001

There are too few respondents to the survey to draw a box-and-whisker for the 'No' respondents, but you can see that the median EDSS for this group was 6.5, compared to 6.0 and 3.0 for this who could cut their toenails with some help or independently, respectively. 

Interestingly, 50% of respondents had difficulty cutting their own toenails. The reasons given for not being able to cut their own toenails are linked to disability, i.e. weakness, inco-ordination, reduced sensation and poor vision. For these reasons I have started asking all my patients if they can cut their own toenails, I inspect their toenails in clinic and if their toenails are in a state of disrepair I offer them a referral to the podiatry clinic. 

To raise awareness of the toenail issue, which is really a hand issue, I launched an 'art project' to collate a series of pictures of the toenails of pwMS and to relate them to levels of physical disability. Pictures are so much better at telling a story. 

The slideshow below represents renditions of pictures of first nine pwMS who have sent in photographs of their toes. I need more pictures to make this project a success. To participate please send me pictures of your toes, with some brief details about your MS and yourself. The pictures will be 'anonymised' and will used as part of our #ThinkHand campaign. 

Please send the following information with your picture to

Sex: M/F
Disease duration:
EDSS: (if you don't know your EDSS you can estimate it using our online calculator)
Are you able to cut your own toenails?:
  • 5 - Yes, easily without help
  • 4 - Yes, independently, but it takes longer than in the past 
  • 3 - Yes, independently, but it takes too long so I often get them cut by someone else
  • 2 - Yes, but I need help
  • 1 - No, I can't cut my in toenails
  • 0 - N/A, I have always had someone else cut my own toenails
Biography: (this is optional please keep this brief)

CoI: ProfG, the Cheerleader for #ThinkHand

Cortical demyelination in Animals

Ücal M, Haindl MT, Adzemovic MZ, Strasser J, Theisl L, Zeitelhofer M, Kraitsy K, Ropele S, Schäfer U, Fazekas F, Hochmeister S. Widespread cortical demyelination of both hemispheres can be induced by injection of pro-inflammatory cytokines via an implanted catheter in the cortex of MOG-immunized rats. Exp Neurol. 2017. pii: S0014-4886(17)30107-3.

Cortical demyelination is a common finding in patients with chronic multiple sclerosis (MS) and contributes to disease progression and overall disability. The exact pathomechanism that leads to cortical lesions is not clear. Research is limited by the fact that standard animal models of multiple sclerosis do not commonly affect the cortex, or if they do in some variants, the cortical demyelination is rather sparse and already remyelinated within a few days. In an attempt to overcome these limitations we implanted a tissue-compatible catheter into the cortex of Dark Agouti rats. After 14 days the rats were immunized with 5μg myelin oligodendrocyte glycoprotein (MOG) in incomplete Freund's Adjuvant, which did not cause any clinical signs but animals developed a stable anti-MOG antibody titre. Then the animals received an injection of proinflammatory cytokines through the catheter. This lead to a demyelination of cortical and subcortical areas starting from day 1 in a cone-like pattern spreading from the catheter area towards the subarachnoid space. On day 3 cortical demyelination already expanded to the contralateral hemisphere and reached its peak between days 9-15 after cytokine injection with a widespread demyelination of cortical and subcortical areas of both hemispheres. Clinically the animals showed only discrete signs of fatigue and recovered completely after day 15. Even on day 30 we still were able to detect demyelination in subpial and intracortical areas along with areas of partial and complete remyelination. Loss of cortical myelin was accompanied with marked microglia activation. A second injection of cytokines through the catheter on day 30 led to a second demyelination phase with the same symptoms, but again no detectable motor dysfunction. Suffering of the animals appeared minor compared to standard Experimental Autoimmune Encephalomyelitis and therefore, even long-term observation and repeated demyelination phases seem ethically acceptable.

Cortical demyelination occurs frequently in MS can this be modelled in rats

The Lisbon Trilogy Slides

This week we have had a lot of interest in our paper with over 3,000 views as the final part of the Lisbon trilogy.

What's the Lisbon Trilogy

Baker D, Herrod SS, Alvarez-Gonzalez C, Zalewski L, Albor C, 
Schmierer K. Both cladribine and alemtuzumab may effect MS via B-cell depletion. Neurol, Neuroimmunol Neuroinflam
4:e360; doi:10.1212/NXI.0000000000000360: 2332-7812

Baker D, Herrod SS, Alvarez-Gonzalez C, Giovannoni G, Schmierer K. Interpreting Lymphocyte Reconstitution Data From the Pivotal Phase 3 Trials of Alemtuzumab. JAMA Neurol. 2017 Jun 12. doi: 10.1001/jamaneurol.2017.0676.

Baker D, Marta M, Pryce G, Giovannoni G, Schmierer K. Memory B Cells are Major Targets for Effective Immunotherapy in Relapsing Multiple Sclerosis. EBioMedicine. 2017;16:41-50. doi: 10.1016/j.ebiom.2017.01.042

and to counter the animal experiments that could follow

Sefia E, Pryce G, Meier UC, Giovannoni G, Baker D Depletion of CD20 B cells fails to inhibit relapsing mouse experimental autoimmune encephalomyelitis. Mult scleros is and related disorders DOI:

ProfG was asked to give a talk on the mechanisms of Action of Antibodies in MS to a group of Antibody Engineers.

ProfG could not attend so he asked me to do it, gave me his 75 slides for a 30min talk.....No chance. 

I had a few weeks to construct a story and plan my slides

So I thought, could I explain how natalizumab, daclizumab, alemtuzumab and ocrelizumab work?

Starting with daclizumab as the odd one out and having the details of of the alemtuzumab and cladribine to hand this is what the audience got.

There was one Neurologist in the Room. 

Saturday, 17 June 2017

#ToeArt: who is more or less disabled?

What can the toes tell us about the lives of people living with MS? #ToeArt #ThinkHand

To find out what these art pieces are about you need to read my earlier post on #ToeArt.

#ClinicSpeak: chemobrain in MS

HSCT or BMT accelerates brain atrophy rates and disability worsening in SPMS. #ClinicSpeak #MSBlog #MSResearch

I am revisiting this old paper to make it a Saturday trilogy of posts on HSCT.

HSCT (hemopoetic stem cell transplantation) or BMT (bone marrow transplantation) requires chemotherapy to ablate or wipe-out your immune system to allow the stem cell transplantation. The chemotherapy drugs that are used are neurotoxic, i.e. they damage the brain.

PwMS who already have pre-existing damage to their brain and spinal cords are particularly susceptible to the neurotoxic effects of chemotherapy. This is also driven by age; the older you are the worse you handle chemotherapy. The oncologists refer to this observation as chemobrain, which is particularly prevalent in the elderly. 

The following study below in which I was involved with shows that when pwMS are given chemotherapy they undergo increased neuronal loss, which is associated with worsening of their EDSS and greater brain atrophy. The data speaks for itself. The picture below is what we call a survival curve of EDSS worsening; you can see that the pwMS who had high blood levels of neurofilaments were much more likely to worsen than those who did not have raised neurofilament levels. Similarly, brain atrophy rates in pwMS were in the order of 2.1% per year in those who had a HSCT compared to only 1.2% per year in pwSPMS who did not have HSCT; the upper limit of normal for brain atrophy in healthy adults is generally accepted to be 0.4% per year. The bottom line is that if you have SPMS HSCT is likely to accelerate your disease worsening. As a result of these and similar observations most units have stopped doing HSCT in people with more advanced MS. However, with the advent of highly-effective DMTs such as alemtuzumab, natalizumab, fingolimod, daclizumab, ocrelizumab and cladribine the number of pwMS needing to be referred for HSCT should be small. 

OBJECTIVE: Chronic neurotoxicity is a recognized long-term complication following chemotherapy in a range of diseases. Neurotoxicity adversely affects patients' quality of life. The objective of this study is to examine whether there is evidence of acute neurotoxicity.

METHODS: This prospective study included MSers with secondary progressive multiple sclerosis (SPMS-BMT, n = 14) and hematological malignancies (HM-BMT, n = 17) receiving chemotherapy as preconditioning for bone marrow transplant. The control groups included SPMSers matched for demographic and clinical data (SPMS-PL, n = 14) and healthy controls (n = 14). Neurodegeneration was assessed at baseline and longitudinally (months 1, 2, 3, 6, 9, 12, 24, and 36), combining a clinical scale for disability (Expanded Disability Status Scale [EDSS]), a serum protein biomarker for neurodegeneration (neurofilaments, NfH-SMI35), and brain atrophy measures (magnetic resonance imaging).

RESULTS: Disability progression was significantly more acute and severe following chemotherapy compared to placebo. Immediately after starting chemotherapy, serum NfH-SMI35 levels increased in 79% (p < 0.0001) of SPMS-BMT MSers and 41% (p < 0.01) of HM-BMT patients compared to 0% of SPMS-PL MSers or healthy controls. In SPMS-BMT serum NfH-SMI35 levels were > 100-fold higher 1 month after chemotherapy (29.73ng/ml) compared to baseline (0.28ng/ml, p < 0.0001). High serum NfH-SMI35 levels persisting for at least 3 months were associated with sustained disability progression on the EDSS (p < 0.05). Brain atrophy rates increased acutely in SPMS-BMT (-2.09) compared to SPMS-PL (-1.18, p < 0.05).

INTERPRETATION: Neurotoxicity is an unwanted acute side effect of aggressive chemotherapy.

CoI: Prof. G was a co-author on this study.

HSCT putting brain loss down to aging

Lee H, Nakamura K, Narayanan S, Brown R, Chen J, Atkins HL, Freedman MS, Arnold DL. Impact of immunoablation and autologous hematopoietic stem cell transplantation on gray and white matter atrophy in multiple sclerosis.Mult Scler. 2017 Jun 1:1352458517715811.

BACKGROUND:Immunoablation and autologous hematopoietic stem cell transplantation (HSCT) halts relapses, white matter (WM) lesion formation, and pathological whole-brain (WB) atrophy in multiple sclerosis (MS) patients. Whether the latter was due to effects on gray matter (GM) or WM warranted further exploration.
OBJECTIVE:To model GM and WM volume changes after HSCT to further understand the effects seen on WB atrophy.
METHODS: GM and WM volume changes were calculated from serial baseline and follow-up magnetic resonance imaging (MRI) ranging from 1.5 to 10.5 years in 19 MS patients treated with HSCT.
RESULTS: Accelerated short-term atrophy of 2.1% and 3.2% occurred in GM and WM, respectively, on average. Both busulfan dose and T1LV were significant predictors of WM atrophy, whereas only busulfan was a significant predictor of GM atrophy. Compared to baseline, a significant reduction in GM atrophy, not WM atrophy, was found. The average rates of long-term GM and WM atrophy were -0.18%/year (standard error (SE): 0.083) and -0.07%/year (SE: 0.14), respectively.
CONCLUSION:Chemotherapy-related toxicity affected both GM and WM. WM was further affected by focal T1-weighted lesion-related pathologies. Long-term rates of GM and WM atrophy were comparable to those of normal-aging.

This study  looks at the effect of HSCT on brain atrophy. There appears to be an initial problem of early brain volume lost and although this could be because of loss of inflammation but as profG showed many years ago the drugs used are neurotoxic and cause some nerve damage and this can be seen by neurofilaments (bits of nerves) being found. However with time it looks like brain volume lost is reduced to the level associated with normal aging. This has been seen with alemtuzumab.

HSCT in Progressive MS

Cull G, Hall D, Fabis-Pedrini MJ, Carroll WM, Forster L, Robins F, Ghassemifar R, Crosbie C, Walters S, James I, Augustson B, Kermode AK. Lymphocyte reconstitution following autologous stem cell transplantation for progressive MS. Mult Scler J Exp Transl Clin. 2017 Mar 23;3:2055217317700167

BACKGROUND: Autologous stem cell transplantation (ASCT) for progressive multiple sclerosis (MS) may reset the immune repertoire.
OBJECTIVE:The objective of this paper is to analyse lymphocyte recovery in patients with progressive MS treated with ASCT.
METHODS: Patients with progressive MS not responding to conventional treatment underwent ASCT following conditioning with high-dose cyclophosphamide and anti-thymocyte globulin. Lymphocyte subset analysis was performed before ASCT and for two years following ASCT. Neurological function was assessed by the EDSS before ASCT and for three years post-ASCT.
RESULTS:CD4+ T-cells fell significantly post-transplant and did not return to baseline levels. Recent thymic emigrants and naïve T-cells fell sharply post-transplant but returned to baseline by nine months and twelve months, respectively. T-regulatory cells declined post-transplant and did not return to baseline levels. Th1 and Th2 cells did not change significantly while Th17 cells fell post-transplant but recovered to baseline by six months. Neurological function remained stable in the majority of patients. Progression-free survival was 69% at three years.
CONCLUSION:This study demonstrates major changes in the composition of lymphocyte subsets following ASCT for progressive MS. In particular, ablation and subsequent recovery of thymic output is consistent with the concept that ASCT can reset the immune repertoire in MS patients.

                               We have more in common than that which divides us

This is yet more evidence that some people with progressive MS, benefit from immune modulation. Is it the T cell or the B cell.

Friday, 16 June 2017

#ClinicSpeak: the waiting game

Understanding why healthcare systems have delays is important. #ClinicSpeak #MSBlog #BrainHealth

In response to my post yesterday, on delays in the MS path and comments from you, today's post is an attempt to explain the reason for the waiting game (even in the USA) and its potential consequences. I have also included a survey to explore what are acceptable delays for you as individuals with MS.

The following perspective on why healthcare systems build-in waiting times into their services is self-explanatory. If you want to optimise the use of resources and maximise profits you need waiting lists. Waiting lists means you maximise the use of your staff and healthcare infrastructure. Healthcare is big business and has to generate income and return on investment. The NHS is no exception, but due to under-investment the NHS tends to push this policy to the extreme and as a result there are major consequences for people with MS and other diseases. The NHS tries to address the latter issues by using triage systems for prioritising urgent problems, for example the 2-week target for cancer.

Healthcare provider's who have no waiting times have to invest in extra, or spare, capacity to meet fluctuating demand. Excess capacity costs money and these providers simply charge more for their services. This is why the Mayo Clinic and the Cleveland Clinic, who were mentioned in comments yesterday, charge more than other providers. The extra charges pay for spare, or idle, capacity that these and other institutions have. So in reality waiting lists are dictated by finances.

Ryu & Lee. The Waiting Game — Why Providers May Fail to Reduce Wait Times. N Engl J Med 2017; 376:2309-2311.


.... When patients wait weeks or months for physician’s appointments, bad things happen. Some adverse consequences are emotional: patients become anxious and even angry. Some are clinical, such as medical issues that worsen, especially if patients don’t show up when their appointments finally roll around.

..... But other consequences of long waits are financial, and they help explain why most health care providers have dragged their feet in cutting waiting times for all types of visits, but particularly for specialty care. Redesigning care to reduce waits requires investing in systems, may reduce revenue, and will irritate physicians who like to control their schedules.

...... Understanding the financial dynamics of the “Waiting Game” can clarify the strategic context in which waiting times are most likely to fall. It also sheds light on the implications of fee-for-service versus value-based payment methods for the way practices and systems approach the access conundrum.

...... Waiting has emotional effects on patients. Uncertainty causes anguish, particularly in patients concerned that disease may be progressing and intervention opportunities may be lost. Other variables such as teamwork, communication, and empathy are more powerful drivers of patients’ likelihood of recommending clinicians to others, but no one likes to wait. Data reveal a dose–response effect: the longer the wait, the lower patients’ satisfaction with care. When patients have to wait weeks for a specialist appointment, their satisfaction falls off a cliff.

...... Given this trend, it’s ironic that physicians often cite long waiting times as evidence of their excellence. Physicians and practice administrators rationalize delays by noting that they’re already working flat out and demand for their services is simply too great. Most deny that they like having long waiting lists, but when their lists shorten they worry that competitors are taking their business. In a fee-for-service environment, physicians dread having open slots in their schedules, bringing in no revenue while expenses mount.

...... The longer patients wait for their appointments, the greater the chance that they won’t show up (see graph Relationship between Waiting Times for Appointments and No-Show Rates.). No-shows are as problematic from a fiscal perspective as unfilled schedule slots. To reduce their impact, practices often “double-book” patients, which makes volume surge when all patients show up. The result may be chaos, with angry patients waiting an hour or more and dispirited clinicians and staff trying to both appease and care for them.

...... In short, it requires recognizing that the Waiting Game provides rewards for letting patients wait, or at least makes investments in reducing waits less attractive than other uses of providers’ resources. But as providers compete on their ability to improve value for patients, the Waiting Game should be subsumed under the more strategic challenges of attracting patients and meeting their needs as efficiently as possible.

Attention Alemtuzumab users: When is an Inhibitory Antibody not an Inhibitory Antibody? When its Neutralizing!!

Free Grant Idea of the Month
#ClinicSpeak #NewsSpeak

If you are using, taking or thinking of taking alemtuzumab you need to read all of this post. At the very least the bottom bit.Tweet, Retweet and Facebook or whatever to your circle of friends

  To continue explaining our recent paper and the last bit for Detective Week, so MD is back in his Civvies next week.

Interpreting Lymphocyte Reconstitution Data From the Pivotal Phase 3 Trials of Alemtuzumab David Baker, Samuel S. Herrod; Cesar Alvarez-Gonzalez,Gavin Giovannoni; Klaus Schmierer
JAMA Neurol. Published online June 12, 2017. doi:10.1001/jamaneurol.2017.0676

Meaning Controlling this B-cell hyperrepopulation after alemtuzumab administration may limit the risk for secondary autoimmunity if administration can be performed safely.

  • Alemtuzumab induces binding (could cause allergic infusion reactions and could stop drug having optimum effect) and neutralizing (could stop drug working) antibodies in most people. 
  • These issues were known, but not reported clearly in pivotal trial results
  • They are a problem for some people and the drug does not work
  • The neutralizing antibodies increase with time and the third/forth injection cycle may be more problematical
  • Should there be a test be repeat infusions?
  • Some people do not respond to alemtuzumab.

We have shown that alemtuzumab blocks tolerance induction and that it does not deplete B cells from the bone marrow or lymphoid tissues well. 

It only takes about 6 days to make an antibody response, with 3-4 days to sensitize a T cell so within a day of finishing the 5 day infusion you could have an anti-drug response because all the immune system is seeing in those first few days is loads of alemtuzumab

We knew that there is an anti-globulin response as it had been reported, as had ways to reduce them.

Somerfield J, Hill-Cawthorne GA, Lin A, Zandi MS, McCarthy C, Jones JL, Willcox M, Shaw D, Thompson SA, Compston AS, Hale G, Waldmann H, Coles AJ.A novel strategy to reduce the immunogenicity of biological therapies.J Immunol. 2010185(1):763-8.

Those studies talked about the high incidence of antibodies that bound to alemtuzumab. This did not specifically mention neutralizing antibodies that would block alemtuzumab function,

Normally this type of information is published in pivotal phase III antibody trials.

However, anti-alemtuzumab antibodies only received cursory mention in the pivotal trial reports, save to say they were of no importance. Neutralizing antibodies other than those to beta interferon (control group) where not mentioned

So it made us do more digging

The Prof Coles had done an open access paper that you can all read.(CLICK ON ME) Alasdair J. ColesAlemtuzumab Therapy for Multiple Sclerosis Neurotherapeutics. 2013; 10(1): 29–33.
There is a section:


"Despite being humanized, alemtuzumab induces anti-alemtuzumab binding and neutralizing antibodies in as much as 30 to 70 % of patients 1 month after the first and second cycles, respectively. However, because the interval between treatment cycles is at least 1 year, such antibodies usually become undetectable before the next cycle [24]". 

These were not mentioned in the pivotal trial report. Why not?

So 30% after 1 month.  Is this right? 

Well let's look at the data.
Someone shouldn't have prompted us to hunt, by saying they don't exist. They do! 

You don't have to do a freedom of Information to find the information it can be found here.

CLICK HERE) Turn to page 34/35

It says on page 34

"The majority of patients (691/811, 85.2%) treated with 12 mg/day alemtuzumab in the pooled Phase 3 studies tested positive for anti-alemtuzumab antibodies. Of the 85.2% of patients who tested positive for anti-alemtuzumab antibodies at any time-point during the course of the study, 92.2% (637/691) tested positive for inhibitory antibodies".

Therefore, that makes about 78% of people having neutralizing antibodies to a humanised antibody that depletes T and B cells. This is staggering. Chimeric mouse human anti CD20 only makes 15-25% of people develop binding antibodies in the same time frame.  Humanized anti CD20 induced less than 1% neutralizing antibody response according to data presented at ECTRIMS

Now turn to page 35
So at 1 month after first injection there is a whopping 62.4% of people making binding antibody and of them 86.8% make inhibitory antibody so 86.8% of 62.4% = about 54%, so 30% is a bit low.
At month 13 after the second injection it was 94.3% of 83.2% = about 78%
However, without access to the actual individual data points this is just an estimate.

These were not mentioned in the pivotal trial report in a way that explains this. Why not?

What happened in the phase II?

Coles A. J., D. A. Compston, K. W. Selmaj, S. L. Lake, S. Moran,
D. H. Margolin, K. Norris,P. K. Tandon,CAMMS223 Trial Investigators
. 2008. Alemtuzumab vs. interferon beta-1a in early multiple sclerosis. N. Engl. J. Med. 359: 1786–1801

In the phase 2 study in patients with early relapsing–remitting multiple sclerosis, alemtuzumab was given as annual cycles. "Most patients’ anti-globulin responses had resolved prior to the second and third exposures. They reported reported that only 1 of 208 (0.5%) and 51 of 194 patients (26.3%) had significant alemtuzumab-binding Abs (above a pre-specified threshold of 2000 U/ml) at months 12 and 24". 

So sounds like not much of a problem but reports in rheumatoid arthritis indicated there was over 60% of people making antibodies within twelve months, so is this a fudge by the phase II investigators to downplay the antibody response?

Does it tell us that thresholds above 2000U/ml are important and if so important for what? Adverse events? Blockade of Function?

It was not mentioned, how many people had a low titre below 2000U/ml, maybe we should have guessed it must have been 50% of the sample as the figures for the phase II are 29.3% verses 75.4% in the phase III. Furthermore no mention of neutralising antibodies.

Now, you may argue that the data is there for all to read...but it is clearly not well known otherwise I would have not been told that neutralizing antibodies don't exist. 

A humanized antibody creating neutralizing antibodies in about 70-80% of people, tells you there is something weird going on. Alemtuzumab was the first humanised antibody and this was designed to reduce immunogenicity., but it must be a relative effect as it is clearly immunogenic.

Anti-Drug antibodies may be consistent with alemtuzumab blocking immune tolerance, as we have reported (as a cause of secondary autoimmunities) this week.

We thought it was surprising that this information has been omitted from the phase III write up. 

But the information could be found.
Those EMA chaps, called it neutralizing (pg 89) so Google search picked up a search for "alemtuzumab" and "neutralizing antibodies" 
Missed the stuff of (pg35) about "inhibitory antibodies" completely. 

Why the name change of a very well-defined term?   

If you look at the table above. What does a titre of 6.5 million mean?

In the table we can see levels of antibody at up to 6.5 million
Titre = the concentration of an antibody, as determined by finding the highest dilution at which it is still able to cause agglutination of the antigen
So it means someone made a shed load of antibody against alemtuzumab!
It would take about 6 days to make an neutralizing antibody from scratch, about 3 days to make the T cells and then they help the B cells. So first set of doses taking 5 days it would be no problem. It would have killed the T and B cells before it could be stopped. 
The second cycle would be OK too because only 0.6% (5/789) of people would have neutralizing antibodies present at the time of infusion but if there is a need for a third infusion which occurs in about 50% of people then about 31% (239/764) have pre-existing neutralizing responses and this could cause problems. However the level (titre) many be low so it is not devistatingly important. Also 75% of people have pre-existing binding antibodies and this could lead to allergic reactions. In the reports I only found 1 case of anaphylaxis although 239 people had pre-existing antibody. So the risk is low. However once generated antibody responses will persist
for life and may be boosted each time you get a new course.
It is published that alemtuzumab does not block vaccine responses and so plasma cells and the T cells that help them (T-dependence) make antibody, persist.

McCarthy CL, Tuohy O, Compston DA, Kumararatne DS, Coles AJ, Jones JL.Immune competence after alemtuzumab treatment of multiple sclerosis. Neurology. 2013;81(10):872-6

So as you can't have it both ways once the antibody forming cells are created some must survive to become active the next time it sees its target and for people with alemtuzumab making antibodies after the first round of injections, the next time is day 1 of the second set of infusions by day 2 those plasma cells will have woken up. Hopefully not enough by day 3 to stop the antibody depleting.

In the CARE-MS  documents we received, some effort is made to show that the presence of binding or neutralizing antibodies do not influence depletion, efficacy or infusion responses, we didn't get to see information presented on the individual responses. However not surprising as only 5/789 had pre-existing neutralizing antibodies and so not enough to make a conclusion.

What could this all mean? 
You could get infusion reactions (anaphylaxis as an extreme allergic response. This occurs as a small fraction), but this would be treated with steroids and anti-histamine, which is standard treatment against the infusion reactions that occur in 90% of people anyway. 

So the influence of binding antibodies and anaphylaxis potential is masked.  

However 75 % of people will have circulating antibodies at the end of second infusion cycle and 30% have neutralizing antibodies, so the risks of not depleting on the third cycle is increased. 

Based on what we know this is not a reported problem for the treated population but at the individual level it would be important to see.
A neutralizing antibody response could mean that the drug stops working. Based on that reported, it is said that they were not a problem in the trial. Maybe that is why it wasn't mentioned in the pivotal trial papers..which every one would read if interested in using alemtuzumab.
So as a group it is not important, but it may be important to an individual. 

This is the important point
So if people are in your care or you are taking alemtuzumab the question is are they still depleting and is the depletion maintained? 
What if they are treatment failures and need another dose, about 50% people do. With three treatment cycles the data says that many people do very well so again on mass the drug is working
But what about the people needing 4 or 5 cycles? 

Is the antibody depleting? 
If you know about neutralizing antibodies, you could get them checked or switch treatments if it is not working.

So are neutralising antibodies important?
It is said that in the EMA report that the presence of antibodies are not important in the two year trial on a number of outcomes, in terms of efficacy and safety at the population levels, meaning no eyebrows were raised.

Let's go back to the paper at the top and see what was said in the rest of the immunogenicity section.
"If persistent, neutralizing antibodies become problematic in patients who have received multiple alemtuzumab cycles. We have shown that pre-treatment with an altered version of alemtuzumab, which no longer binds to its target, can effectively induce tolerance to alemtuzumab itself [24]".
So if persistent there is a problem so this issue appears known but again not published properly. Why was this not properly exposed, to show data? A couple of lines in a review is not exposing the problem. 

Am I being a DramaQueen?  If you know the about information above I am a DramaQueen, if not an Investigative Journalist.

Now you can think about this issue if you are treating people or if you are taking the medication.

Now you can say, look at the label

Go to the EMA and you get

It says I'm being a drama queen because such a high level of neutralizing antibodies is misleading. 

Best get your info from the FDA

See. It was there all the time so I'm not revealing anything new.

You just have to look

As it is Friday and you get supplements on Friday, I'll give some extract bits of detective work done since submission, not in the current paper. 

Why do this? I could and perhaps should wait and publish it first.

I do this because I think, you need to know now and shouldn't wait until I publish it (or someone else publishes it). As it may be relevant to you. I know there are people in the World, where this is indeed relevant and the neuros will have a dilema of what to do next.

Are the Anti-Drug responses Important at the Individual level?  Simple answer is Yes.

At the population level, I agree these antibodies have no effect within the trial, however back to the data, I can see two things.

(a) There are people who do not deplete well , independent of anti-drug antibodies

(b) There are people who  do not deplete well because they make anti-drug antibodies.

Looking through the EMA data, since we submitted the paper above, I can find an example of each of these (written and ready to go:-). Now I can't say they didn't deplete because I didn't get the before and after cell counts (I have asked), but one can say they didn't deplete very well. Therefore, there appears to be non-depletors following treatment with alemtuzumab. 

So £28,000 (in the UK) for something that does nothing 

Below is a graph found on the internet that told me to look at the data and told be where to look in the thousands of pages within an EMA document. 

Only the first thirty days are the important period when the cells are being deleted. We did not see it in the EMA stuff we looked at, but this is from the EMA website. (Check it in the document below)

Lemtrada, INN-alemtuzumab - European Medicines Agency 

When you are looking for a needle in a haystack. Graphs are what you need. But raw data is what we need. I have drawn some boxes to help you focus on the points I'm making.

You only look at the first 30-40 days because repopulating B cells skew the data after that.

Is the blue above the red? If it is, does it mean being having anti-drug antibody is important to individuals? They are not depleting as well as those without antibody.

Are there non-depletors?, If there are, is it one in a blue moon?
The graph above suggests there are non-depleters. You can see it is not common. 

I'm not much of a human genome mapper, but there are people out there who are and one could easily look to see how common polymorphisms are to CD52, and other gene products that affect lymphocyte depletion. 

CD52 is a peptide of 12 amino acids, anchored to glycosylphosphatidylinositol (GPI). Since it is highly negatively charged and present on sperm cells and lymphocytes, it has been conjectured that its function is anti-adhesion, allowing cells to freely move around

Turns out there are polymorphisms (differences) in the  CD52 molecule

Oko A, Wyrwicz LS, Glyda M, Idasiak-Piechocka I, Bińczak-Kuleta A, Kaczmarczyk M, Drozd A, Ciechanowicz A, Czekalski S.CD52 gene polymorphism and its potential effect on the response to alemtuzumab in renal transplant recipients.Ann Acad Med Stetin. 2009;55(2):22-6.

CD52 is a small glycopeptide leukocyte antigen present on selected subpopulations of human cells. From the clinical point of view this protein is an important target for therapeutic interventions aimed at leukocyte depletion in hematological malignancies and post-transplant immunosuppression. Recently, two variants of CD52--rs1071849 (A119G; Asn40Ser) and rs17645 (A123G; I1e41Met)--were discovered. We now report on the distribution of these variants in kidney graft recipients and controls. Our bioinformatics findings suggest that CD52 polymorphism may affect the efficiency of GPI anchor formation and thus may indirectly alter the response to anti-CD52 agents.

There are no obvious loss of function mutations (i.e. knockouts) when I looked through over 60,000 genomes from the Broad Institute data base. The polymorphisms above are reasonably common meaning about 30-40% of people would be homozygous for these variants. If it truly affects response to alemtuzumab it will be affecting a lot of people. Is this why the blue dots above are higher than the red dots? 

However, there is only one other relatively common polymorphism besides the two above, that occur as homozgotes and this occurs in Latinos. Do they deplete different from the Europeans. A 5 minute bit of data analysis if you have the raw data 

Is it something else I suspect. We know some gene variants affect, how well you deplete. Do they influence responses to Rituximab, ocrelizumab, etc? 

Based on the total population, we can say that in the first two years of treatment, the antibody neutralisation is not an issue, and published data (ECTRIMS2016) shows you can deplete after three or more cycles of alemtuzumab. This was shown in

Boyko AN et al. Lymphocyte depletion and repopulation is consistent across alemtuzumab treatment courses in patients with relapsing-remitting multiple sclerosis: 6-year analysis of patients from the CARE-MS studies . Mult Scler J 2016
ECTRIMS Online Library. Boyko A. Sep 15, 2016; 146494
In patients who received only the original 2 courses of alemtuzumab, mean CD4+, CD8+ and CD19+ counts at the start of Course 2 were 0.28, 0.24 and 0.34 x 10*9/L, respectively. Both T and B lymphocytes were depleted after the second course of alemtuzumab (N=369), reaching their lowest levels at 1 month after Course 2 (mean CD4+: 0.05; mean CD8+: 0.06; mean CD19+: 0.03 x 10*9/L). CD19+ counts repopulated quickly and reached the lower limit of normal (LLN; 0.1 x 10*9/L) by 3 months. T cells repopulated more slowly; CD8+ counts reached LLN (0.2 x 10*9/L) by about 6 months, and CD4+ counts reached LLN (0.5 x 10*9/L) at Month 24. Once reaching plateau (CD19+, 15 months; CD8+, 30 months; CD4+, 24 months), cell counts were stable through 48 months and remained above LLN. Depletion and repopulation of T and B cells were similar after 1 or 2 alemtuzumab retreatments (Course 3: n=79; Course 4: n=10).

(see it takes 2 years for CD4 levels to return to the lower normal limit so this may be why it takes 2 years for the secondary autoimmunities to occur and you can see the CD8 cells (regulatory cells) are back quicker so the pathogenic cells return in a regulated environment.) 

At the population level there is deletion and activity as can be seen above, but in the responders the CD4 level at 6 months post alemtuzumab is about 0.2 x 10*9, but in the failers requiring another cycle the CD4 level appears around 0.4 x 10*9 in the 6 months before retreatment. Is this relevant?

What is the deletion after cycle 1, cycle 2 and cycle 3 and cycle 4 and how does this relate to neutralizing antibodies? What is the data at the individual level?.  What is the titre of antibody that is clinically relevant for lack of efficacy. It looks like the data is there to address this pretty quickly.

There was no mention of depletion failures in the MS CARE extension abstracts (Boyko et al 2016) or phase II data 

Kousin-Ezewu O, Azzopardi L, Parker RA, Tuohy O, Compston A, Coles A, Jones J.Accelerated lymphocyte recovery after alemtuzumab does not predict multiple sclerosis activity.
Neurology. 2014 Jun 17;82(24):2158-64

An omission or does it simply not happen, that there are no people who do not respond well to treatment? I suspect the occurance of this is low.

However, some people do stop responding to alemtuzumab and the logical reason is due to antibody neutralisation, it happens with all protein therapeutics. Again we have to go no further than the internet and do some digging and some data interpretation. 

We can go back to published data that was used to say that it is safe to go onto fingolimod after alemtuzumab. The lymphocyte number was shown for 13 individuals who failed alemtuzumab and went onto fingolimod. Six people had three cycles and it is clear that the two people in the bottom panels I selected stopped depleting. Probably because of neutralizing antibodies.

These people need to be changed, together they got about £60,000 worth of antibody to do nothing. 

Importantly, it gets even more complicated because after alemtuzumab, it can cause white blood cells to become CD52 negative and so unresponsive to drug.

Brett SJ, Baxter G, Cooper H, Rowan W, Regan T, Tite J, Rapson N.Emergence of CD52-, glycosylphosphatidylinositol-anchor-deficient lymphocytes in rheumatoid arthritis patients following Campath-1H treatment. Int Immunol. 1996;8(3):325-34.

CD52 is a glycosylphosphatidyl-inositol (GPI)-linked glycoprotein expressed at high levels on normal T and B lymphocytes and at lower levels on monocytes, while being absent on granulocytes and bone marrow stem cell precursors. The emergence of CD52- lymphocytes of both T and B cell lineages was observed in three out of 25 rheumatoid arthritis patients treated with the humanized antibody Campath-1H in phase II clinical trial. 

Whereas the majority of CD52- B cells had disappeared from the peripheral blood by 3 months post-treatment, both CD52- CD4+ and CD8+ T cells persisted in the circulation for at least 20 months. In the two patients that were tested, the GPI-anchored surface molecules CD55 and CD59 were also absent on the CD52- cells, although expression of other cell surface transmembrane, proteins (CD3, CD4 and CD2) was unaffected. The CD52- cells maintained a stable phenotype in vitro despite repeated re-stimulation in culture. Both CD52- and C52+ clones, established from one of the patients, responded to a similar extent to several T cell mitogens, as assessed by proliferation, suggesting that a general defect in expression of GPI-linked molecules does not impair T cell activation. These data show that an immune attack against a GPI-anchored surface molecule can result in the selection of a GPI-anchor-deficient cell population. Despite the persistence of CD52- T cells in the peripheral blood, no adverse reactions associated with the presence of these cells were noted in any of the patients; in fact they responded with longer remission times after Campath-1H treatment than the other patients in the trial.

So if MS is a problem of B cells then they will still be dealt with..phew? If it is a T cell issue then 12% of people may not deplete as well as they could. Does this happen in MS?.

This is due to cross linking of CD52 this can be done with alemtuzumab but would be augmented by binding antibodies cross-linking the alemtuzumab binding to CD52. Thus crosslinking CD52

I could have kept this last bit of detective work quiet, so I could publish it first.

But if you are using/recieving alemtuzumab I think you should know and monitor your depletion. If you are not depleting, are you neutralizing the response? and do you need to think about a switch?

Now that the existence of neutralizing antibodies is in the open in the academic literature in a searchable way, there will be a race to publish the first case that neutralizing antibodies actually impact MS at the individual level.

I guess you realise there are probably two places with a head start if they trawl their data, but as you can see it is all there already if you know where to look. (However in the cases above you don't know if they had neutralizing antibodies), but I know it happens.

If you are a non-depletors (on first infusion) maybe get you neuro to give ProfG an email, so we can try work out why, if this not known already, depletion may not be that good. I will volunteer to do this, we have the technology, but we don't have the cash:-(.

It may determine whether you can switch to another IgG1, as we know certain genes determine whether you deplete with rituximab too, or whether you need an non-antibody treatment.

Is this an issue for ocrelizumab? 

This bit of pharmacogenomics may help inform treatment choices.

However, if you are not depleting maybe it is time to change. 

Maybe it is time to Publish the data, so that we don't have to dig to find the information. The answer is there.

CoI: None.  DrK, ProfG multiple