Wednesday, 17 May 2017

#ClinicSpeak & #ResearchSpeak: daclizumab's impact on cognitive function

How important is your cognition to you? Will it influence your choice of DMT? #ClinicSpeak #ResearchSpeak

I have made the case many times to reclassify, or rebrand, MS a preventable dementia. The majority of people with MS have cognitive impairment and it is almost certainly the most important cause of unemployment in early MS. 50% of pwMS in Europe are unemployed at an EDSS level (3.0-3.5); a level of disability that is not associated with overt physical disability. PwMS at these low EDSS levels rarely complain of specific cognitive symptoms, but rather the more pernicious symptom of cognitive fatigue. The brain is remarkably good at compensating for cognitive deficits by working harder by using new areas of undamaged brain (plasticity), which increases energy consumption; the result is cognitive fatigue. 


Many patients tell me that 30 minutes of deep concentration makes them feel like they have just studied all night and completed a 3 hour school of university examination. This level of cognitive exhaustion is why so many pwMS simply can't compete in the knowledge economy. 

On this backdrop it is reassuring to finally have data to support the use of daclizumab, one of the high-efficacy DMTs, over an existing interferon-beta formulation, to delay, or prevent, worsening of MS-related cognitive problems. Subjects who received daclizumab in the DECIDE phase 3 trial had greater improvement from baseline in the performance of the Symbol Digit Modalities Test (SDMT) compared to subjects treated with IFN beta-1a. More pwMS treated with daclizumab had a clinically meaningful improvement in SDMT and less chance of worsening than subjects  treated with interferon-beta. The SDMT is a well-validated cognitive outcome measure that correlates with cognitive impairment on formal testing, long-term disease outcomes or disability and gray and whole brain atrophy. 

Are these observations unique to daclizumab, or will they be seen with all high-efficacy DMTs? These results are possibly unique to daclizumab. DECIDE is the first trial to convincingly show that a specific DMT has a positive impact on cognitive outcomes. Could the unique mode of action of daclizumab be relevant? Daclizumab expands a population of cells from the hard-wired, or innate, immune system called natural killer cells (NK cells). NK cells have many properties, but one of them are antiviral effects. If MS is due to a virus then these NK cells may target and clear the virus from the central nervous system. This may be particularly relevant if low-grade viral infection(s), for example with EBV or HERVs (human endogenous retroviruses), are what is driving the slow burn within the brains of pwMS. Daclizumab may be protecting your cognition by clearing the virus in the cortical gray matter. 

I think the importance of  this data cannot be under-estimated. People with MS in the know may value their cognition more than other neurological functions and hence this data is likely to become an important differentiator of daclizumab from the other high-efficacy DMTs.

  

BACKGROUND: Cognitive impairment is common in multiple sclerosis (MS), with cognitive processing speed being the most frequently affected domain.

OBJECTIVE: Examine the effects of daclizumab beta versus intramuscular (IM) interferon (IFN) beta-1a on cognitive processing speed as assessed by Symbol Digit Modalities Test (SDMT).

METHODS: In DECIDE, patients with relapsing-remitting multiple sclerosis (RRMS) (age: 18-55 years; Expanded Disability Status Scale (EDSS) score 0-5.0) were randomized to daclizumab beta ( n = 919) or IM IFN beta-1a ( n = 922) for 96-144 weeks. SDMT was administered at baseline and at 24-week intervals.

RESULTS: At week 96, significantly greater mean improvement from baseline in SDMT was observed with daclizumab beta versus IM IFN beta-1a ( p = 0.0274). Significantly more patients treated with daclizumab beta showed clinically meaningful improvement in SDMT (increase from baseline of ⩾3 points ( p = 0.0153) or ⩾4 points ( p = 0.0366)), and significantly fewer patients showed clinically meaningful worsening (decrease from baseline of ⩾3 points ( p = 0.0103)). Odds representing risk of worsening versus stability or improvement on SDMT were significantly smaller for daclizumab beta ( p = 0.0088 (3-point threshold); p = 0.0267 (4-point threshold)). In patients completing 144 weeks of treatment, the effects of daclizumab beta were generally sustained.

CONCLUSION:  These results provide evidence for a benefit of daclizumab beta versus IM IFN beta-1a on cognitive processing speed in RRMS.

CoI: multiple

10 comments:

  1. Cognitive function protection is great, but there seems to be safety issues to take into consideration. I read this on the MS Trust site (https://www.mstrust.org.uk/a-z/daclizumab-zinbryta):

    Side effects

    In clinical trials, serious infections, serious skin reactions and impaired liver function occurred more frequently in people treated with daclizumab than in other treatment groups.

    In the SELECT study, serious infections, serious skin reactions and impaired liver function occurred more frequently in people treated with daclizumab than in the placebo group.

    Among the 517 treated in SELECTION there were 13 cases of serious infections, six of serious skin reactions, eight cases of impaired liver function and three cases of autoimmune reactions.

    There was one death in SELECT resulting from a complication of an abscess in a muscle of the lower back in a patient recovering from a serious skin reaction, and one in the SELECTION extension study, thought to be due to autoimmune hepatitis, where the body's own immune system attacks cells of the liver.

    In the DECIDE trial serious side effects occurred more often in the group taking daclizumab compared to beta interferon: serious infections (4% vs 2%), serious skin reactions (2% vs less than 1%) and raised liver enzyme levels (6% vs 3%).

    ReplyDelete
    Replies
    1. Yes, there are risks as with all DMTs. Unfortunately, no DMTs is without risks.

      Delete
  2. So what will be the place of Dac in the future? First- or second line? Highly- or moderately effective?

    ReplyDelete
  3. According to market survey initial price of a single-dose prefilled syringe of zinbryta costs about 7000$ - 7600$

    Should we compare of label(cheaper) drugs vs this "highly efective" costly drugs?
    Why all the studys out there ,dont compare cost and efficacy of drugs?
    Thanks Luis

    ReplyDelete
    Replies
    1. It costs a fifth of this price in the UK. Time the US politicians did something about MS drug prices.

      Delete
    2. New drug for motor neuron disease...its an anti-oxidant discovered in Japan (edaravone) and sold for a few thousand bucks but now it is FDA approved the price tag is $150,000. Maybe the politicians have extra stuff on their plate.

      I shouldn't bang the drum generic CLAD:-),

      Delete
  4. You said:
    "DECIDE is the first trial to convincingly show that a specific DMT has a positive impact on cognitive outcomes."

    They authors wrote:
    "First, DECIDE was not powered to study the effects of daclizumab beta on cognitive function;"
    "Finally, the SDMT does not provide an exhaustive assessment of cognitive function; rather, it is used to assess a relatively narrow range of cognitive ability, "

    and some other study limitations. Among them, huge dropouts (919/922 at baseline --> 287/277 at week 144) and a complex algorithm to compensate for almost 40% of missing data.

    In other words, nothing to celebrate or take seriously into account, despite the great effort of statisticians.

    ReplyDelete
    Replies
    1. The primary endpoints were to determine effect on disease activityn and progression. This secondary study was an add on to the study.
      You omitted for some strange reason that the authors also stated "That said, the large sample size was more than adequate to determine a small but reliable effect" (on cognitive ability).
      I'm afraid your nit-picking is unwarranted.

      Delete

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