Thursday, 23 March 2017

Natural Killer cells and MS

Natural killer cell subpopulations are associated with MRI activity in a relapsing-remitting multiple sclerosis patient cohort from Australia.Caruana P, Lemmert K, Ribbons K, Lea R, Lechner-Scott J. Mult Scler. 2016:1352458516679267. doi: 10.1177/1352458516679267

To examine NK subsets in MS patients on different treatments and to evaluate the role of NK subsets as indicators for disease activity.
METHODS:We measured NK subset levels in blood obtained from 110 relapsing-remitting MS patients. Patients were either off treatment or on treatment with natalizumab, fingolimod, glatiramer acetate or beta-interferon. Disease activity was defined according to 'No Evidence of Disease Activity' (NEDA) criteria within an observation period of up to 2.4 years. The mean NK subset levels were compared among treatment groups using multivariate analysis of variance (ANOVA) and association analysis with disease activity performed using multi-factor logistic regression.
RESULTS: Our analysis revealed differences in NK cells and subsets on treatment compared to off treatment ( p < 0.0005). A high proportion of bright NK cells were significantly associated with stable magnetic resonance imaging (MRI) imaging after adjusting for treatment effects ( p < 0.05).
CONCLUSION: The independent association of NK subsets with MRI stability needs to be confirmed in prospective studies to test their usefulness in predicting disease activity in MS patients.

So a suggestion that NKbright cells that are expanded by daclizumab in this study they suggest high levels are associated with stable disease...Is this a sign that its not B cells?

#PoliticalSpeak & #OffLabel: it is okay to use off-label DMTs

Off-label prescribing; how do we get it adopted? #PoliticalSpeak #MSBlog #OffLabel
My number one book from my homeland, South Africa. 

'Who knows for what we live, and struggle, and die? Wise men write many books, in words too hard to understand. But this, the purpose of our lives, the end of all our struggle, is beyond all human wisdom.'

'You ask yourself not if this or that is expedient, but if it is right.'

'There is only one way in which one can endure man's inhumanity to man and that is to try, in one's own life, to exemplify man's humanity to man.'

'I envision someday a great, peaceful South Africa in which the world will take pride, a nation in which each of many different groups will be making its own creative contribution.'

'To give up the task of reforming society is to give up one's responsibility as a free man.'

'Cry, the beloved country, for the unborn child that is the inheritor of our fear. Let him not love the earth too deeply... For fear will rob him of all if he gives too much.'

Alan Paton

One of the most important issues we have tried to address on this blog in access to effective DMTs for pwMS in resource-poor settings. I had a Skype call with a young neurologist from South Africa yesterday and she informs me that she has not been able to get permission to start any of her patients on a licensed DMT in the last 18 months. In addition, she is unable to offer these patients off-label subcutaneous generic cladribine or leflunomide as these drugs are not licensed in South Africa for MS. This is a true Catch-22! 

These and other experiences of what it is like to be a pwMS living in a resource-poor country remains our primary motivator for this policy initiative. We will continue to promote the use of off-label, cheaper, alternative DMTs to treat MS. What we need is some action. I wish politicians would read this blog and meet pwMS face-to-face. May be it should be them who say you can't have drug x, or drug y, and explain to them why.

The following is our essential off-label DMT list (click on each drug for more information):

CoI: multiple

Wednesday, 22 March 2017

ClinicSpeak; gardening post-alemtuzumab

Another opportunistic infection associated with alemtuzumab use in a person with MS. #MSBlog #ClinicSpeak

Question: "I am day 12 day after last alemtuzumab dose and probably have lymphopenia/leukopenia at the moment. Should I avoid the garden this spring :-(?"

Answer: Yes, you are putting yourself at risk of Nocardial infection. Nocardia species live in the soil. There have been cases described post alemtuzumab (see below). 

The first case below presented with a 3-week history of cough, shortness of breath, and a high fever 8 weeks after the first cycle of alemtuzumab treatment. Nocardia are aerobic gram-positive bacteria found in soil and water.  Nocardia is an opportunistic infection and needs to be taken very seriously. At the moment nocardial infections are rare and I am not sure what the risk is post-alemtuzumab. However, whilst you are neutropaenic and lymphopaenic I would advise avoiding soil exposure. 

Nocardia in the brain at autopsy; image from Wikipedia

Sheikh-Taha & Corman. Pulmonary Nocardia beijingensis infection associated with the use of alemtuzumab in a patient with multiple sclerosis. Mult Scler. 2017 Feb 1:1352458517694431.

Nocardia is a Gram-positive aerobic pathogen that usually affects immunocompromised patients. We report a case of pulmonary infection caused by a rare Nocardia species, Nocardia beijingensis, in a 50-year-old woman who had received alemtuzumab for the treatment of her multiple sclerosis. The invasive pulmonary infection was successfully treated with meropenem.

Penkert et al. Fulminant Central Nervous System Nocardiosis in a Patient Treated With Alemtuzumab for Relapsing-Remitting Multiple Sclerosis. JAMA Neurol. 2016 Jun 1;73(6):757-9.

#ClinicSpeak & #Neurospeak: low platelets with alemtuzumab

Not all low platelet counts post-alemtuzumab are due to ITP. #ClinicSpeak #NeuroSpeak #MSBlog

I received a query from a colleague a few months ago about a low platelet count in one their patients treated with alemtuzumab. The low platelet count was in the first week, it was transient and was not due to ITP. We became aware of this a few years ago and dropped Professor Coles an email about the observation. He sent us this picture from his thesis (below) and reassured us that the low platelet count will be transient and it was. The explanation he provided is that platelets stick to blood vessels due to adhesion molecule expression secondary to the cytokine release that occurs with alemtuzumab. In his experience, and our experience, this is nothing to worry about. I hope this helps. 

Background: Alemtuzumab is a monoclonal antibody approved for relapsing-remitting multiple sclerosis (RRMS). Although Immune thrombocytopenia (ITP) has been reported as a secondary autoimmune phenomenon following alemtuzumab infusion, immediate thrombocytopenia during the infusion has not been reported.

Objective: We report transient, reversible, self-limiting acute-onset thrombocytopenia during the first course with alemtuzumab.

Results and conclusion: In total, 3 of 22 paitents developed mild self-limited bruising associated with a drop in platelet count from their baseline during the intial 5-day course of alemtuzumab. Upon chart review, all 22 patients who received alemtuzumab developed an immediate mostly asymptomatic drop in platelet count which returned to normal within 2 months post-infusion.

CoI: multiple

Imaging hot microglia.

Datta G, Colasanti A, Kalk N, Owen DR, Scott G, Rabiner EI, Gunn R, Lingford-Hughes A, Malik O, Ciccarelli O, Nicholas R, Nie L, Battaglini M, De Stefano N, Matthews P.
[11C]PBR28 or [18F]PBR111 detect white matter inflammatory heterogeneity in multiple sclerosis.J Nucl Med. 2017. pii: jnumed.116.187161. doi: 10.2967/jnumed.116.187161. [Epub ahead of print]
Objective: To assess microglial activation in lesions and in normal appearing white matter of multiple sclerosis (MS) patients using positron emission tomography (PET). 
Methods: 34 MS patients (7 with secondary progressive MS (SPMS), 27 with relapsing remitting MS (RRMS)) and 30 healthy volunteers, genetically stratified for translocator protein (TSPO), binding status underwent PET scanning with TSPO radioligands (11C-PBR28 or 18F-PBR111). Regional TSPO availability was measured as a distribution volume ratio (DVR) relative to the caudate (a pseudo-reference region). White matter lesions (WML) were classified as "active" (DVR highest in the lesion), "peripherally active" (peri-lesional DVR highest), "inactive" (DVR highest in surrounding normal appearing white matter, NAWM) or "undifferentiated" (similar DVR across lesion, peri-lesional and NAWM volumes). 
Results: The mean DVR in NAWM of patients was greater than that of the healthy volunteer white matter for both radioligands. Uptake for individual WML in patients was heterogeneous, but the median WML DVR and NAWM DVR for individual patients were strongly correlated (ρ = 0.94, P = 4x10-11). A higher proportion of lesions were inactive in patients with SPMS (35 %) than RRMS (23 %), but active lesions were found in all patients, including those on highly efficacious treatments. 
Conclusion: TSPO radioligand uptake was increased in brains of MS patients relative to healthy controls with two TSPO radiotracers. WML showed heterogeneous patterns of uptake. Active lesions were found in patients with both RRMS and SPMS. 

Translocator protein (TSPO) is an 18 kDa protein mainly found on the outer mitochondrial membrane. It was first described as peripheral benzodiazepine receptor (PBR), a secondary binding site for diazepam, but subsequent research has found the receptor to be expressed throughout the body and brain.

TSPO has been proposed to interact with StAR (steroidogenic acute regulatory protein) to transport cholesterol into mitochondria. It has been suggested to be a marker of microglial activation. 

In this study they reported more activity in MS and found lesions in relapsing and SPMS and the lesions were more active in relapsing rather than SPMS, but still there are active lesions. So as we have been saying, RRMS and SPMS are not distinct. 

However, it gives an indication of the presence of hot microglia, it  seems increasingly evident that there is a broader activity than just microglia so we have to interpret the data more cautiously

#GuestPost & #NeuroSpeak: Neuro-Compass

How useful is Neuro-Compass as a tool to help manage MS? #GuestPost #Neurospeak

The following is a guest post from Professor David Bates explaining the aims of Neuro-Compass. This is a follow-up post on yesterdays guest post from Dr Overell on the DMT Toolbox. 

Professor Bates has agreed to answer questions on the post for the next 7 days; so please keep him busy (very busy).

CoI: multiple, Neuro-Compass is sponsored by an unrestricted grant from Biogen

Tuesday, 21 March 2017

#DigestingScience at Great Ormond Street hospital

On Saturday we were at Great Ormond Street to take part in their educational day for families affected by demyelinating conditions.

Although the Digesting Science activities were originally designed to teach children aged 6 - 12 about their parents MS, they can also teach children about their own condition. The morning was really inspiring and we met some amazing young people with a good turn out of under-13's and teenagers.

There were lots of questions about genetics, treatments and simple things like how to manage fatigue. One teenager had a brilliant outlook on life. He was experimenting with different ways to manage his fatigue so he could still go to the gym with friends and work out, without completely wearing himself out.

Mouse Dr took over the treatment activity with Dr Sara Simeoni from UCLH on walking. 

If your interested in coming along to a Digesting Science event, the next London date is Saturday the 13th May in Whitechapel which you can book onto via eventbrite:

If your not based around London, we've been supporting teams to run Digesting Science events for their families in Dorset, Gosport and Norwich with three events for young carers happening over the next two months across Surrey. There's a kit going Wales with the MS Society and some of the activities have been used in Sheffield with the MS Research team there. If you would like to run an event in your area - please get in touch!

#GuestPost & #NeuroSpeak: Dr James Overell describes the DMT toolbox

New digital tools for MS clinical practice available on Neuro-Compass. #GuestPost #Neurospeak

I hope you are enjoying our flurry of guest posts? We are deliberately trying to increase the number; we know that you are bored of hearing the same-old stuff from us over-and-over again. 

A few week's ago I was introduced to Neuro-Compass a web-portal for HCPs working in the MS space. I was particularly impressed with the DMT Toolbox to help decision-making around DMTs in clinical practice. I have always wanted to create a tool like this for pwMS, but have not had the time. James Overell a colleague of mine, who works in Glasgow, led on the development of this particular feature of the portal. When I saw him at the UK MS Debating Society meeting a few weeks ago I extracted a guest post out of him for the blog. 

James produced, or his team at Neuro-Compass, produced a fully formatted post with pictures, etc. in the form of a word document. To save time I have embedded the post as a PDF. If I had to reformat this using HTML, on blogger, it would have taken at least 30 minutes and probably longer. If you don't mind reading guest posts as embedded documents we could use this format more often and increase the number of posts. I have also asked Professor David Bates, the chairman of the Neuro-Compass site to do a guest post as well to explain the aim of the site. 

Please let us know what you think of the portal? Dr Overell has agreed to answer questions on the post for the next 7 days; so please keep him busy. 

CoI: multiple

Don't write off a write-off: a reassessment of Teriflunomide

Mult Scler. 2017 Mar 1:1352458517695468. doi: 10.1177/1352458517695468. [Epub ahead of print]

The efficacy of teriflunomide in patients who received prior disease-modifying treatments: Subgroup analyses of the teriflunomide phase 3 TEMSO and TOWER studies.

Freedman MS, Wolinsky JS, Comi G, Kappos L, Olsson TP, Miller AE, Thangavelu K, Benamor M, Truffinet P, O'Connor PW; TEMSO and TOWER Study Groups.


Teriflunomide is a once-daily oral immunomodulator approved for relapsing-remitting multiple sclerosis (MS). The objective of this post hoc analysis of the phase 3, pooled TEMSO (NCT00134563) and TOWER (NCT00751881) dataset is to evaluate the effect of teriflunomide treatment on annualised relapse rate and disability worsening across patient subgroups defined according to prior disease-modifying therapy exposure. This analysis provides further supportive evidence for a consistent effect of teriflunomide across a broad range of patients with relapsing MS, including patients who have used and discontinued other disease-modifying therapies.

Figure:   (a) ARR by prior treatment; (b) Disability worsening by prior treatment. Teriflunomide shows a trend towards improvement, including those who have received prior DMT, but the effect is not statistically significant.

Teriflunomide (Aubagio), a first-line oral MS therapy has an Achilles heel, and that is its side-effects; particularly irksome are liver problems (requiring frequent blood tests), diarrhoea, and hair thinning/loss. They occur often enough that they overshadow it's selling point as an alternative to dimethyl fumerate (Tecfidera), which has the PML risk. Teriflunomide blocks rapidly dividing cells and this includes activated T cells by inhibiting pyrimidine (building blocks of genes) synthesis.

Here the TEMSO and TOWER study groups (these were the two of the clinical trials performed prior to licensing of teriflunomide) reanalyse the pooled data by dividing those into ones who received disease-modifying therapies (DMT) before and those who had not, i.e. DMT naïve. Most included in the analysis were DMT naïve with ~30% having used one or more DMT (so this is a 2:1 analysis so to speak). The most frequently used other DMT was interferon beta (IFNβ). Overall, there is a numerical reduction in relapse rate and risk of disability progression with teriflunomide 14mg compared to all the subgroups analysed (see Figure above). The differences, however, are not significant and should be born in mind. The authors point out that this may be due to the small size of the groups analysed but I feel the numbers were sufficient even if it's a post-hoc analysis. Interestingly, they also noted that those who had prior DMTs also had greater MRI activity with more enhancing lesions and relapse rates compared to the treatment-naïve group, which is concerning (those who participated had to be off their DMTs for 3-6 months prior to inclusion) and implies rebound after coming off treatment. The latter is a practical lesson to learn for clinicians swapping treatments.

Overall, despite the less than impressive data, teriflunomide in my books will remain a first-line contender by simply not following the paths trodden by others. It does not pretend to achieve the excellence of the second generation DMTs, nor does it imitate those who are most excellent, and as such, will remain a prudent man's/woman's choice.

Monday, 20 March 2017

What Did the B Cell Video Miss?

Many Years (1994) Ago, 
I made an (immortalised) B cell Line. 
Here are the Pictures (low power on left).  
On cell surface (on the right) there are little blobs. 
What were they?
They were Budding Virus Particles

So Maybe the New B cell Video
didn't miss a trick. 
Here's the B cell containing Little blobs too.
They get infected with Virus in Humans, notably in MS

A Black Swan Idea

Anti-CD20 kills Immature to Memory Cells, 
Alemtuzumab (anti-CD52) really kills the memory B cells
Maybe B cell Depletion Kills the Virus

Maybe that is why they work?

Maybe Not a T cell Issue...Food For Thought

#NeuroSpeak: blast from the past cladribine MOA

Telling complicated stories through slick Pharma-funded movies. #NeuroSpeak #MSBlog

Whilst we on the topic of critiquing slick videos on the modes of action of DMTs it may be a good idea to review the oral cladribine MOA video from 6 years ago; yes, it has been 6 years since oral cladribine was launched in Australia. 

The oral cladribine video is much longer than the Roche-funded anti-CD20 video you may have seen this weekend. Cladribine is a smart drug that uses very clever biochemistry to target T and B cells. Does the video do the job of communicating this or do we need to something simpler?

CoI: multiple and this video was funded by Merck

Predicting MS Activity

Håkansson I, Tisell A, Cassel P, Blennow K, Zetterberg H, Lundberg P, Dahle C, Vrethem M, Ernerudh J.Eur J Neurol. 2017 . doi: 10.1111/ene.13274. [Epub ahead of print]


Improved biomarkers are needed to facilitate clinical decision-making and as surrogate endpoints in clinical trials in multiple sclerosis (MS). We assessed whether neurodegenerative and neuroinflammatory markers in cerebrospinal fluid (CSF) at initial sampling could predict disease activity during 2 years of follow-up in patients with clinically isolated syndrome (CIS) and relapsing-remitting MS.


Using multiplex bead array and enzyme-linked immunosorbent assay, CXCL1, CXCL8, CXCL10, CXCL13, CCL20, CCL22, neurofilament light chain (NFL), neurofilament heavy chain, glial fibrillary acidic protein, chitinase-3-like-1, matrix metalloproteinase-9 and osteopontin were analysed in CSF from 41 patients with CIS or relapsing-remitting MS and 22 healthy controls. Disease activity (relapses, magnetic resonance imaging activity or disability worsening) in patients was recorded during 2 years of follow-up in this prospective longitudinal cohort study.


In a logistic regression analysis model, NFL in CSF at baseline emerged as the best predictive marker, correctly classifying 93% of patients who showed evidence of disease activity during 2 years of follow-up and 67% of patients who did not, with an overall proportion of 85% (33 of 39 patients) correctly classified. Combining NFL with either neurofilament heavy chain or osteopontin resulted in 87% overall correctly classified patients, whereas combining NFL with a chemokine did not improve results.


This study demonstrates the potential prognostic value of NFL in baseline CSF in CIS and relapsing-remitting MS and supports its use as a predictive biomarker of disease activity.

Neurofilaments in spinal fluid is a reasonable predictor of disease activity. We have said this many times

Recognition of viral and self-antigens by TH1 and TH1/TH17 central memory cells in patients with multiple sclerosis reveals distinct roles in immune surveillance and relapses.

Recognition of viral and self-antigens by TH1 and TH1/TH17 central memory cells in patients with multiple sclerosis reveals distinct roles in immune surveillance and relapses.Paroni M, Maltese V, De Simone M, Ranzani V, Larghi P, Fenoglio C, Pietroboni AM, De Riz MA, Crosti MC, Maglie S, Moro M, Caprioli F, Rossi R, Rossetti G, Galimberti D, Pagani M, Scarpini E, Abrignani S, Geginat J. Recognition of viral and self-antigens by TH1 and TH1/TH17 central memory cells in patients with multiple sclerosis reveals distinct roles in immune surveillance and relapses.
J Allergy Clin Immunol. 2017. pii: S0091-6749(17)30043-X. doi: 10.1016/j.jaci.2016.11.045. [Epub ahead of print]

BACKGROUND:Multiple sclerosis (MS) is an inflammatory demyelinating disease of the central nervous system (CNS) that is caused by autoreactive T cells and associated with viral infections. However, the phenotype of pathogenic T cells in peripheral blood remains to be defined, and how viruses promote MS is debated.
OBJECTIVE:We aimed to identify and characterize potentially pathogenic autoreactive T cells, as well as protective antiviral T cells, in patients with MS.
METHODS:We analyzed CD4+ helper T-cell subsets from peripheral blood or cerebrospinal fluid for cytokine production, gene expression, plasticity, homing potentials, and their reactivity to self-antigens and viral antigens in healthy subjects and patients with MS. Moreover, we monitored their frequencies in untreated and fingolimod- or natalizumab-treated patients with MS.
RESULTS: TH1/TH17 central memory (TH1/TH17CM) cells were selectively increased in peripheral blood of patients with relapsing-remitting MS with a high disease score. TH1/TH17CM cells were closely related to conventional TH17 cells but had more pathogenic features. In particular, they could shuttle between lymph nodes and the CNS and produced encephalitogenic cytokines. The cerebrospinal fluid of patients with active MS was enriched for CXCL10 and contained mainly CXCR3-expressing TH1 and TH1/TH17 subsets. However, while TH1 cells responded consistently to viruses, TH1/TH17CM cells reacted strongly with John Cunningham virus in healthy subjects but responded instead to myelin-derived self-antigens in patients with MS. Fingolimod and natalizumab therapies efficiently targeted autoreactive TH1/TH17CM cells but also blocked virus-specific TH1 cells.
CONCLUSIONS: We propose that autoreactive TH1/TH17CM cells expand in patients with MS and promote relapses after bystander recruitment to the CNS, whereas TH1 cells perform immune surveillance. Thus the selective targeting of TH1/TH17 cells could inhibit relapses without causing John Cunningham virus-dependent progressive multifocal encephalomyelitis

We have been tooing and frowing between T cells and B cells and this swings back to T cells

Sunday, 19 March 2017

Viral Infections can be a problem

Clerico M, De Mercanti S, Artusi CA, Durelli L, Naismith RT. Active CMV infection in two patients with multiple sclerosis treated with alemtuzumab. Mult Scler. 2017 Feb 1:1352458516688350. doi: 10.1177/1352458516688350. [Epub ahead of print]
Alemtuzumab is a humanized monoclonal antibody targeting the surface molecule CD52, resulting in a rapid depletion of innate and adaptive immune cells. Infection rates in multiple sclerosis (MS) treatment trials were higher in alemtuzumab than in interferon beta-treated patients. We report two MS patients who developed cytomegalovirus disease within 1 month after the first 5-day cycle of alemtuzumab. Upon identification and appropriate treatment of the infection, each recovered completely. Neurologists should be aware of this serious but treatable complication.

So there you are warned. CMV is a common virus in humans and is a problem if you are immunosuppressed. It appears it can be a problem in mice too

Murine Cytomegalovirus Infection Induces Susceptibility to EAE in Resistant BALB/c Mice.Milovanovic J, Popovic B, Milovanovic M, Kvestak D, Arsenijevic A, Stojanovic B, Tanaskovic I, Krmpotic A, Arsenijevic N, Jonjic S, Lukic ML.Front Immunol. 2017;8:192. doi: 10.3389/fimmu.2017.00192.

In contrast to C57BL/6 mice, BALB/c mice are relatively resistant to the induction of experimental autoimmune encephalomyelitis (EAE) after challenge with MOG35-55 peptide. Here, we provide the first evidence that infection with murine cytomegalovirus (MCMV) in adulthood abrogates this resistance. Infected BALB/c mice developed clinical and histological signs similar to those seen in susceptible C57BL/6 mice. In addition to CD4+ cells, large proportion of cells in the infiltrate of diseased BALB/c mice was CD8+, similar with findings in multiple sclerosis. CD8+ cells that responded to ex vivo restimulation with MOG35-55 were not specific for viral epitopes pp89 and m164. MCMV infection favors proinflammatory type of dendritic cells (CD86+CD40+CD11c+) in the peripheral lymph organs, M1 type of microglia in central nervous system, and increases development of Th1/Th17 encephalitogenic cells. This study indicates that MCMV may enhance autoimmune neuropathology and abrogate inherent resistance to EAE in mouse strain by enhancing proinflammatory phenotype of antigen-presenting cells, Th1/Th17, and CD8 response to MOG35-55.

How times change when I first started with EAE, we had the SJL and the PL mouse and BALB/c and notably C57BL/6 were classed as the most genetically resistant mouse strains on the planet. 

This is becuase people were using myelin basic protein or proteolipid protein to induce EAE. We first showed that myelinoligodendrocyte glycoprotein (MOG) in mice.

Amor S, Groome N, Linington C, Morris MM, Dornmair K, Gardinier MV, Matthieu JM, Baker D. Identification of epitopes of myelin oligodendrocyte glycoprotein for the induction of experimental allergic encephalomyelitis in SJL and Biozzi AB/H mice.J Immunol. 1994;153:4349-56.

Then it was shown shortly after that C57BL/6 mice could get MOG induced EAE, using the MOG35-55 that we showed induced disease in ABH (H-2g7= Kd, Ag7, E-, Dq transplantation antigen type that determines which peptides they respond to) mice.
This opened up the use of knockout mice which were typically made on the C57BL/6 (H-2b) or 129 (H-2b) mouse background.

We showed also that the MOG35-55 peptide commonly used may not have been the best peptide in C57BL/6 (H-2Ab) mice
Delarasse C, Smith P, Baker D, Amor S.Novel pathogenic epitopes of myelin oligodendrocyte glycoprotein induce experimental autoimmune encephalomyelitis in C57BL/6 mice. Immunology. 2013;140(4):456-64. doi: 10.1111/imm.12155.

This was repeated a year later, by a group from West Coast USA that forgot not to acknowledge the existence of the early discovery (Bad Science)-
 I'm not bitter:-)

This is great and bad because C57BL/6 is still a weak susceptibility background and shows gene related differences that disappear as unimportant once you do the same experiment in a high susceptibility strain

Genetic background can result in a marked or minimal effect of gene knockout (GPR55 and CB2 receptor) in experimental autoimmune encephalomyelitis models of multiple sclerosis.
Sisay S, Pryce G, Jackson SJ, Tanner C, Ross RA, Michael GJ, Selwood DL, Giovannoni G, Baker D.PLoS One. 2013 Oct 9;8(10):e76907. 

We also showed that BALB/c mice were other low susceptiblity strain can be induced to develop disease.

Croxford JL, O'Neill JK, Baker D.Polygenic control of experimental allergic encephalomyelitis in Biozzi ABH and BALB/c mice.J Neuroimmunol. 1997;74(1-2):205-11

So in this study they find that infection of BALB/c (H-2d) mice with CMV makes them susceptible to EAE with MOG35-55.
They get alot of CD8 to respond ,so that will be by Kd or Dd molecule by which they are restricted, and it is interesting in ABH mice (Kd, dq) get disease and we have noticed more CD8 cells in the CNS when mice are immunised with this peptide. 

It also induced monophasic chronic disease that becomes progressive from first attack in ABH and C57BL/6 mice whereas MOG8-22 (residues 8-22 in the MOG molecule) get relapsing disease. So saying that genetics does not necessarily dictate disease course.

It also says that viral infection can influence susceptibility, which is known too and this was how PL/J were found to EAE susceptible after infection with mouse hepatitis virus.

Cross AH, McCarron R, McFarlin DE, Raine CS.Adoptively transferred acute and chronic relapsing autoimmune encephalomyelitis in the PL/J mouse and observations on altered pathology by intercurrent virus infection. Lab Invest. 1987; 57:499-512.

#ClinicSpeak: mode of action of B cell therapy in MS

What is missing from the anti-B-cell narrative? #ClinicSpeak #MSBlog

Will anti-B-cell therapies become the agents of choice for treating both the relapsing and advanced stages of MS. Another slick video explaining the mode of action of anti-B-cell therapies. 

What is missing? I think the narrative in this video is incomplete. Can you spot was is missing? 

CoI: multiple, the production of this video has been funded by Roche

Saturday, 18 March 2017

#ClinicSpeak & #ThinkSpeak: ruminations and thoughts about more advanced MS

What needs to be done to tackle 'progressive' or more correctly 'advanced' MS? #ClinicSpeak #ThinkSpeak #MSBlog

I had a meeting with colleagues earlier this week to discuss what needs to be done to tackle progressive MS; i.e. from an academic perspective. The following are some of my thoughts.

  1. We all need to accept that ‘progressive MS’ is misnomer. Progression means improvement. We prefer the term ‘advanced MS’ this captures the associated disability that comes with this phase of the disease.
  2. We need to accept that the pathology that drives neuroaxonal loss, or neurodegeneration (the pathological substrate that underlies ‘advanced MS’) as being there from the beginning. This means the neurodegenerative phase of MS is present from the beginning, before pwMS become physically disabled.
  3. MS is 1-disease and not 2-3-or-4-diseases. As I have said before the false division of MS into several diseases is not backed up by science, nor by philosophical arguments. This false division of MS into many diseases has become counter-productive to the field of MS. The division of MS into relapsing and progressive forms was Pharma-led to get MS defined as an orphan disease, which allowed interferon-beta-1b to get a license based on the results of one pivotal phase 3 study. It also allowed the company concerned to charge rather a lot of money for its product. Overall this has been good for MS in that it has attracted a lot of Pharma interest and has supercharged drug development in MS, but it is now slowing down drug development and making it very expensive. We need cheaper drugs for advanced MS; disability affects the cost-effectiveness models for reimbursement hence DMTs for advanced MS need to be priced lower than those for relapsing forms of MS.
  4. Following on the point above the division between SPMS and PPMS is false. There is no pathological, genetic, imaging or other data that suggests these are different entities. We therefore should be doing trials in both populations simultaneously.
  5. Slay the dogma that more advanced MS has reduced inflammation, or is non-inflammatory. There is clinical, imaging and pathological data that shows inflammation plays a big part in driving advanced MS. Therefore not to target more advanced MS with an anti-inflammatory is folly.  
  6. Accept that reserve capacity in particular systems plays an important part in how MS worsens. Neuronal systems with reserve are more likely to be able to recover function and hence show a treatment effect compared to neuronal systems in which reserve capacity is exhausted. In the latter systems it will simply take longer to show a treatment effect; we refer to this as therapeutic-lag. These observations are explained by the length-dependent axonopathy hypothesis. This means that we will need to focus more on arm-and-hand function as a primary outcome in pwMS who have lost too much function in their lower limbs (EDSS>=6.0).
  7. Challenge the dogma that once someone has lost lower limb function and is a wheelchair user that the disease is not modifiable. We have good data that DMTs can slow the worsening of upper limb function despite subjects being wheelchair-bound. We feel very strongly about this point and are very keen that future trials in advanced MS include wheelchair users. Why should we write-off people with MS who have lost leg function? What keeps pwMS independent and functioning in society is arm and hand function. We as a community have to think about that very carefully. We have rehearsed these arguments many times as part of our #ThinkHand campaign.
  8. Accept that we will need to use combination therapies to make a real difference to more advanced MS. I am not necessarily talking about two anti-inflammatories, but an anti-inflammatory targeting adaptive immune responses in combination with a neuroprotective therapy. I agree there is a good argument for combining an anti-inflammatory that targets innate immune mechanisms - for example laquinimod which targets hot microglia - with a classic anti-inflammatory against targeting adaptive immune mechanisms.
  9. We need to ditch the EDSS. The whole community knows that the EDSS is not fit for purpose in more advanced MS. We need to get the regulators to accept this. We also need to work on a set of outcome measures that capture the whole impact of MS on someone with MS. We are getting there with the new rendition of the MS functional composite. But in my opinion this is not enough. We need more PROMS in the battery, in particular a better hand-and-arm function PROM. We are aware that there are several out there and some are in development.
  10. We need to think creatively about our trial design. I am not an expert here, but some in the community are pushing for adaptive trials, i.e. a multi-arm phase 2 trial with a seamless design allowing it to be converted into a phase 3 study. Pharma don’t like adaptive designs nor do the regulators. I do think we do need two phases to trials in more advanced MS, i.e. the standard head-to-head phase with a robust primary outcome, say a multi-outcome composite, followed by an open-label extension where the study subjects remain blinded to their original treatment allocation. This will allow us to capture therapeutic lag. If we had done this we would have had licensed treatments for more advanced MS decades ago. The logic behind this trial design is explained in detail in our length-dependent axonopathy paper (see below).
  11. Acceptance of more sensitive biomarkers to get proof-of-concept trials done more quickly. I know I am biased, but I really think neurofilament level monitoring in the CSF and blood will provide us with this tool. This means we will be able to do phase 2 studies a lot quicker and more cheaply than we have done them in the past. We have finally fully recruited our PROXIMUS trial and we have learnt a lot in the process. I will do a separate post in the near future on the lessons learnt from PROXIMUS. For those of you new to this blog the PROXIMUS trial was an add-on neuroprotective trial in which we add oxcarbazepine, a sodium channel blocker, on top of an existing DMT in subjects with ‘early SPMS’.
  12. Political changes are needed to incentivise the repurposing of off-patent drugs. We have discussed this on this blog endlessly and have even written a paper on the so called ‘Big Pharma Alternative’ to explain our thoughts on this.
  13. Regulatory changes are also required. We need to get the FDA and EMA to accept wheelchair users in trials. Some of my colleagues think this is a big issue; I don’t. If we do a trial and provide compelling data that drug x in combination with drug y delays, or stops, worsening disability in upper limb function in pwMS in wheelchairs they would be obliged to license the combination, provided it was safe. What we need from them however is to accept the need for combination therapies. MS is a complex disease and hence will need a complex solution to tackle it, i.e. combination therapies, this is not rocket science and happens all the time in other disease areas for example oncology.
  14. More detailed cost-effective models that focus on loss of upper-limb function and bulbar function (swallowing and speech) are needed. It is clear from the recent EU cost of MS study that costs soar as pwMS lose arm function.
  15. We also need to tackle ageing and its impact on worsening MS. I think the evidence that early, or premature, ageing from reduced brain, and cognitive, reserve drives worsening MS in older pwMS, is beyond doubt. What we need is some way of dissecting-out premature ageing from MS-specific mechanisms. Another issue with ageing is the emergence of comorbidities as a driver of worsening MS, in particular smoking, hypertension, hypercholesterolaemia, metabolic syndrome, diabetes and a sedentary lifestyle. I sit on many trial steering committees and we deal with this problem by simply putting an age cap on the trial population. This is the main reason why trials in advanced MS usually have a ceiling of say 55, or 60, years of age. This is ageist and we must develop better tools for dealing with this issue.  
  16. We need to manage expectations. PwMS are expecting an effective treatment to restore function or return them to normal. The latter is not going to happen. The best we can expect is to slow down the rate of worsening disability, or flat-line their disability, with anti-inflammatory and neuroprotective strategies. I say this knowing that in pathways with reserve capacity there is a possibility of improvement in function, but not enough improvement for me to falsely raise their hopes . To get substantial and meaningful improvements in disability we need new treatment strategies, possibly remyelination therapies that work, but we will almost certainly need treatments that promote axonal sprouting, synaptogenesis and plasticity mechanisms to restore function.

As you can see I am passionate about tackling more advanced MS. I personally think we have thrown-out many babies (DMTs) with the bathwater. Why? We haven’t thought deeply enough about some of the issues highlighted in the points above. We need to start a serious debate about these issues and get on with the job of protecting arm and hand function in pwMS.

Giovannoni et al. Is multiple sclerosis a length-dependent central axonopathy? The case for therapeutic lag and the asynchronous progressive MS hypotheses. Mult Scler Relat Disord. 2017 Feb;12:70-78.

Trials of anti-inflammatory therapies in non-relapsing progressive multiple sclerosis (MS) have been stubbornly negative except recently for an anti-CD20 therapy in primary progressive MS and a S1P modulator siponimod in secondary progressive MS. We argue that this might be because trials have been too short and have focused on assessing neuronal pathways, with insufficient reserve capacity, as the core component of the primary outcome. Delayed neuroaxonal degeneration primed by prior inflammation is not expected to respond to disease-modifying therapies targeting MS-specific mechanisms. However, anti-inflammatory therapies may modify these damaged pathways, but with a therapeutic lag that may take years to manifest. Based on these observations we propose that clinically apparent neurodegenerative components of progressive MS may occur in a length-dependent manner and asynchronously. If this hypothesis is confirmed it may have major implications for the future design of progressive MS trials.

CoI: multiple

Guest Post: Denise Fitzgerald. Treg (regulatory) cells can also be T regenerative cells

Dr Denise Fitzgerald is a Neuroimmunologist based 
at Queens University Belfast, Northern Ireland

Dr Denise Fitzgerald, who herself experienced a condition similar to MS, called Transverse Myelitis when she was 21. As a result of inflammation in her spinal cord, she was paralysed in less than two hours. Dr Fitzgerald had to learn to walk again as the damage in her spinal cord repaired itself over the following months and years. 

We are delighted that she has agreed to do a guest-post on her recent publication in the Journal Nature Neuroscience, which is about the subject of repair.  

Dr Fitzgerald says

"This early-stage study in mouse models has identified that a subset of T cells known as regulatory T cells (Treg) are important for efficient regeneration of myelin in the CNS. 

Tregs are anti-inflammatory T cells that help to resolve inflammation and we hypothesised that these cells would be beneficial in regeneration of CNS tissue that should ideally occur with resolution of inflammation. 

It is challenging to study myelin regeneration in humans and especially challenging to study it in the absence of Tregs so we used a mouse model that collaborators shared with us in which we could delete Tregs at specific times. 

We found that following myelin damage, remyelination in both spinal cord and brain was significantly impaired when mice did not have Tregs and this could be restored when animals were given ‘normal’ Tregs.

We next studied the effect of Tregs on brain tissue in a dish which has two key advantages; it reduces the number of experiments in live animals and it zones in on interactions between immune cells and the neural tissue itself, which helps work out how Tregs may be working. 

In this brain tissue model we observed that the production of myelin was accelerated by addition of Treg cells or even just by adding products released by Tregs (the soup!). 

This could have been due to the anti-inflammatory effect of Tregs because this brain tissue is in an inflamed state when it is first prepared, but even when we allowed the tissue to ‘rest’ for 7 days to allow local inflammation signals to subside, Treg soups still accelerated myelin production. 

This suggested to us that these observations were very different to the classical anti-inflammatory functions of Treg so we next zoned in on target cells.

One reason for impaired remyelination is that oligodendrocyte progenitor cells can get stuck in an immature state and not develop into myelin-producing cells (oligodendrocytes). 

In our early spinal cord experiments we had observed that mice without Tregs had normal numbers of oligodendrocyte progenitor cells after demyelination but few differentiated (mature) oligodendrocytes so we hypothesised that Tregs promoted oligodendrocyte differentiation. 

To test this, we added Treg soups to glial cells growing in dishes and indeed observed significantly enhanced conversion of oligodendrocyte progenitor cells to ‘mature’ cells. 

It was still possible however that other glial cells in the culture that are involved in inflammatory responses (e.g. astrocytes, microglia) were mediating this effect  of Treg so we turned to our collaborators in UCSF (University of California San Franscisco) to test the effect of Treg soups in pure oligodendrocyte progenitor cell cultures. We were very encouraged when they reported back that not only did Treg soups drive the development of mature oligodendrocytes but also myelination of neurons in culture! 

Together, these sets of experiments identified that Treg were directly signaling to progenitor cells in the CNS, to carry out a function very different to known anti-inflammatory roles.

The next key question was  - how were Tregs promoting oligodendrocyte differentiation? As immunologists, our natural choice would have been to test for known immune products of Treg but we were trying to work out a ‘regenerative’ mechanism of Treg. Hence, we chose to measure around 50 proteins known to be involved in regeneration of other types of tissue instead. 

It was through this approach that we stumbled upon CCN3, a protein that was not known to be produced by T cells of any type or to have an effect on oligodendrocyte progenitor cells. 

CCN3 is a complex protein, structurally and functionally, and for this reason we took two approaches to studying whether CCN3 was important in Treg-driven oligodendrocyte differentiation and myelin production. 

We first added an antibody that would bind to (and potentially neutralise) CCN3 in Treg soups and we also captured the CCN3 and removed it from soups using beads and magnets. 

In both cases, the capacity for Treg soups to promote oligodendrocyte differentiation and myelination was significantly impaired, identifying a key role for CCN3. Finally, we added the captured CCN3 to brain tissue in a dish and found that this was sufficient to drive myelin production.

In summary, in mouse experimental models we have identified a new role for Treg in promoting myelin production in the brain and spinal cord and a key part of this mechanism is CCN3, though there are likely other mechanisms also (T cells rarely rely on just one way of doing things!). 

While we are very excited about the possibilities that these discoveries open, we do not want to raise false or premature hope. 

This is an early-stage study done entirely in mice. We don’t yet know how much of this translates to humans (we have started this) or how realistic it will be to make a remyelinating treatment from this knowledge. 

These are all questions we are addressing with support from the Wellcome Trust and BBSRC (Biotechnology and Biological Sciences Research Council) and the new Northern Ireland MS Research Network of patients, scientists and clinicians, through which we are recruiting 300 volunteers that are kindly providing blood samples for our work.

As an immunologist, one of the most positive aspects of this study was how much support we received from our neuroscience collaborators particularly Robin Franklin, Jonah Chan and Anna Williams

This international team helped our team of immunologists to set up a range of CNS experimental models in our lab, shared protocols, performed experiments, hosted our visiting scientists and generally kept us right on all things ‘oligodendrocyte’!" 

You can read the paper here

Dombrowski Y, O'Hagan T, Dittmer M, Penalva R, Mayoral SR, Bankhead P, Fleville S, Eleftheriadis G, Zhao C, Naughton M, Hassan R, Moffat J, Falconer J, Boyd A, Hamilton P, Allen IV, Kissenpfennig A, Moynagh PN, Evergren E, Perbal B, Williams AC, Ingram RJ, Chan JR, Franklin RJ, Fitzgerald DC. Regulatory T cells promote myelin regeneration in the central nervous system.
Nat Neurosci. 2017. doi: 10.1038/nn.4528. [Epub ahead of print]

Regeneration of CNS myelin involves differentiation of oligodendrocytes from oligodendrocyte progenitor cells. In multiple sclerosis, remyelination can fail despite abundant oligodendrocyte progenitor cells, suggesting impairment of oligodendrocyte differentiation. T cells infiltrate the CNS in multiple sclerosis, yet little is known about T cell functions in remyelination.  We report that regulatory T cells (Treg) promote oligodendrocyte differentiation and (re)myelination. Treg-deficient mice exhibited substantially impaired remyelination and oligodendrocyte differentiation, which was rescued by adoptive transfer of Treg. In brain slice cultures, Treg accelerated developmental myelination and remyelination, even in the absence of overt inflammation. Treg directly promoted oligodendrocyte progenitor cell differentiation and myelination in vitro. We identified CCN3 as a Treg-derived mediator of oligodendrocyte differentiation and myelination in vitro.  These findings reveal a new regenerative function of Treg in the CNS, distinct from immunomodulation. Although the cells were originally named 'Treg' to reflect immunoregulatory roles, this also captures emerging, regenerative Treg functions.

CoI: None relevant