Selected highlights from the American Academy of Neurology annual meeting, Seattle WA, 2-7 April 2022.
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DMTs and vaccine response
Age and outcomes
Biomarkers
Radiologically isolated syndrome (RIS)
Clinical practice
CONGRESS HIGHLIGHTS – MONDAY EDITION
Over 500 articles have now reported on the effect of DMTs on COVID-19 vaccine response and a meta-analysis (N=1239 patients) is now available (Gombolay et al. AAN 2022;S5.007). Overall, antibody responses were detected in 100% of untreated MS patients and those receiving glatiramer acetate, dimethyl fumarate, teriflunomide, natalizumab or alemtuzumab; 99% in healthy controls or patients on beta-interferons; 93% on cladribine; 70% on S1PR agents; and 46% on anti-CD20 agents. Antibody response was higher with rituximab compared to ocrelizumab (62% vs. 39%).
While older age at MS onset has been associated with worse 10-year outcomes, a new study has found that younger age at onset is associated with worse outcomes at age 50 years (Bose et al. AAN 2022;P17.008). The study looked at outcomes at age 50 in 550 MS patients with >10 years’ disease duration. Mean age at MS onset was 30.8 years; 86.9% started treatment with a first-line injectable; and 38.5% switched to a high-efficacy DMT during the clinical course. The EDSS score was 0.42 points worse for every 5-year increment that symptoms developed earlier. Earlier onset was associated with a higher risk of SPMS (OR 1.56), greater T2 lesion volume (1.16 cm3) and greater brain atrophy (brain parenchymal fraction 0.55% lower). It is unclear if outcomes would have been more favourable in this cohort if higher-efficacy therapies had been available earlier in the clinical course.
Serum neurofilament-light chain (sNfL) has been proposed as a biomarker of inflammatory disease activity. An Italian study reported that sNfL levels were elevated in 72% of patients with clinical activity and 75% of patients with new MRI lesions (Malucchi et al. AAN 2022;S19.001). In addition, 10% of NEDA patients had elevated sNfL, which may indicate an impending loss of NEDA.
A separate study found that elevated baseline sNfL was predictive of loss of NEDA or new MRI lesions but not of relapses (Lin et al. AAN 2022;S19.005). Adding OCT measures (ganglion cell and inner plexiform layer [GCIPL] thinning) improved the prognostic value: abnormal NfL + GCIPL thinning was predictive of loss of NEDA (HR 3.61), new MRI lesion (HR 3.19) and new relapse (HR 5.38).
A pilot study at St. Michael’s Hospital, Toronto, reported that plasma NfL levels were significantly higher in subjects with radiologically isolated syndrome (RIS) with a high lesion load (>20 lesions with the central vein sign or >50 white-matter lesions) compared to healthy controls (Schneider et al. AAN 2022). The authors suggested that NfL may be useful in identifying RIS subjects at higher risk of developing MS.
Radiologically isolated syndrome (RIS)
A Canadian study (CanProCo) obtained 3T brain MRIs in 14 RIS subjects (mean age 50 years) and compared them to 14 healthy controls (Glaister et al. AAN 2022;P15.010). RIS was associated with lower cerebellar hemispheric gray-matter volume; this was most apparent along the lateral edges of the cerebellar hemispheres. RIS was also associated with increased whole-brain atrophy and atrophy of the right frontal medial cortex. The authors noted that the cerebellum may be the site of early tissue loss in RIS.
A NARCOMS survey reported that 20% of MS patients are current cannabis users (N=3240 respondents) (Fox et al. AAN 2022;P10.003). The most common sources of medical guidance on cannabis use were “nobody/self” (47%) and people working at the dispensary (20%). Dispensaries (45%) or dealers/friends (31%) were the preferred sources for what was in the cannabis product. Patients generally did not ask for guidance on cannabis use from their MS physician (12%) or another physician (11%).
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