Sunday, 22 January 2017

#ClinicSpeak & #ThinkHand: self-compassion

Patient-empowerment and self-management have many benefits; self-compassion being just one of them. #ClinicSpeak #ThinkHand #MSBlog

The study below shows that when pwMS, or other chronic diseases, can self-manage your disease, your physical health depends strongly on the expectancy of a positive outcome (realistic thinking). The corollary is that when options for self-management in controlling your disease are limited (no DMTs, no prevention of infections, no lifestyle modifications, etc.) then your physical health depends more strongly on unrealistic thinking, or dare I say beliefs and/or pseudoscience.

When some pwMS are told that they have passed from the so called 'relapsing phase' to the more 'advanced phase' (formerly called SPMS) they shift from an having an expectancy of a positive outcome to either a 'sense of hopelessness' or in some cases to a phase of 'unrealistic thinking'. For example, several of my patients with more advanced MS have gone onto to explore risky therapies abroad, contrary to my advice, in the hope of curing their MS and reversing their disability. Unfortunately, this phenomenon is fuelled by dogma that states MS is a two-staged disease, the first stage driven by inflammation and the second stage being due to neurodegeneration, and that there is a 'window of opportunity' to treat MS. Many experts in the field simply don't accept the possibility that MS can be modified through-out its course, which perpetuates the problem. 

At Barts-MS we actively promote patient-empowerment and self-management of MS. It is clear that by doing this pwMS learn 'self-compassion'. We also make it clear that we subscribe to the hypothesis that MS is potentially modifiable throughout its course, which is why we have launched our #ThinkHand campaign and explains why we want to do a trial in pwMS with more advanced MS. We want to test whether, or not, a highly-effective anti-inflammatory drug, with CNS penetration, is able to delay worsening of disability in the upper limbs and beyond. We are not deliberately promoting unrealistic expectations; our strategy won't reverse existing disability it is simply being designed on the expectation that we may be able to keep pwMS with more advanced disease independent a little longer. 

Patient-empowerment and self-management have many benefits; they improve anxiety and mood and make pwMS feel the have something to offer. They also teach pwMS to have self-compassion; i.e. extending compassion to one's self in instances of perceived inadequacy, failure, or general suffering (Wikipedia). 

Fournier et al. Optimism and adaptation to chronic disease: The role of optimism in relation to self-care options of type 1 diabetes mellitus, rheumatoid arthritis and multiple sclerosis. Br J Health Psychol. 2002 Nov;7(Part 4):409-432.

OBJECTIVES: To determine the role of optimistic beliefs in adaptation processes of three chronic diseases different in controllability by self-care. It was expected that optimism towards the future would relate to adaptation independently of the controllability of disease. Optimism regarding one's coping ability should be beneficial in controllable diseases. Unrealistic optimism was expected to be beneficial in uncontrollable disease.

DESIGN: The cross-sectional design involved 104 patients with type 1 diabetes, 95 patients with rheumatoid arthritis and 98 patients with multiple sclerosis, recruited via their physician at the out-patient department of five hospitals.

METHOD: Confirmatory Factor Analysis (LISREL) was employed to confirm a three-dimensional approach of optimism: outcome expectancies, efficacy expectancies and unrealistic thinking. Multi-sample analysis by path modelling was used to examine whether the relationship of the three optimistic beliefs with coping (CISS-21), depression and anxiety (HADS), and physical functioning (SF-36) differs with the controllability based on the self-care options of chronic disease.

RESULTS: These show that when chronic disease must be controlled by self-care, physical health depends more strongly on positive efficacy expectancies. In contrast, when self-care options for controlling chronic disease are limited, physical health depends more strongly on positive unrealistic thinking and relates negatively to positive efficacy expectancies. The impact of the three optimistic beliefs on mental health is independent of the controllability by self-care.

CONCLUSION: Optimistic beliefs are differently beneficial for physical health dependent on the controllability of chronic disease. Unrealistic beliefs are helpful when patients are confronted with moderately to largely uncontrollable disease where self-care options are limited, in contrast to positive efficacy expectancies that are helpful when patients deal with largely controllable disease where self-care is required.

Bullet Points to explain something important for people on fingolimod

Willis M, Pearson O, Illes Z, Sejbaek T, Nielsen C, Duddy M, Petheram K, van Munster C, Killestein J, Malmeström C, Tallantyre E, Robertson N. An observational study of alemtuzumab following fingolimod for multiple sclerosis. Neurol Neuroimmunol Neuroinflamm. 2017 Jan 10;4(2):e320.

Yesterday the "Headmaster" complained my post was too complicated.

So maybe we should just do highlights for the people that like their info in sound bites

  • Fingolimod traps T and B cells in Lymph Glands

  • Alemtuzumab kills T and B cells in the Blood

  • However alemtuzumab is not that effective at killing cells in lymph glands and bone marrow

  • Fingolimod can stop Alemtuzumab working
  • Be careful what you do when you switch treatment from fingolimod !

  • More evidence that B cells are the main targets for treatment..hang on shouldn't this be T cells!
  • Maybe more evidence for alemtuzmab neutralizing antibodies
            However, where is the analysis, explanation?  What do you think?

This rebound will not occur in every body. In this study
there were 36 six people, who had used fingolimod before alemtuzumab and the disease activity was seen in 9 people i.e. 25%. Remember, alemtuzumab is not infallible and relapse (4% in the cardiff cohort) in the first year occurs.

Of these people 8/9 were disease free after the second set of infusions

Thou shall have a fishy on a little dishy, thou shall have a fishy when the 3Rs boats come in

Kulkarni P, Yellanki S, Medishetti R, Sriram D, Saxena U, Yogeeswari P. Novel Zebrafish EAE model: A quick in vivo screen for multiple sclerosis. Mult Scler Relat Disord. 2017 Jan;11:32-39. doi: 10.1016/j.msard.2016.11.010.


Pre-clinical drug discovery for multiple sclerosis (MS) is a labor intensive activity to perform in rodent models. This is owing to the long duration of disease induction and observation of treatment effects in an experimental autoimmune encephalomyelitis (EAE) model. We propose a novel adult zebrafish based model which offers a quick and simple protocol that can used to screen candidates as a step between in vitro experiments and rodent studies. The experiments conducted for this manuscript were to standardize a suitable model of EAE in adult zebrafish and validate it using known modulators.


The EAE model was developed by disease induction with myelin oligodendrocyte glycoprotein - 35-55 (MOG) and observation of survival, clinical signs and body weight changes. We have validated this model using fingolimod. We have further performed detailed validation using dimethyl fumarate, dexamethasone and SR1001, which are known modulators of rodent EAE.


The immunization dose for the disease induction was observed to be 0.6mg/ml of MOG in CFA (Complete Freund's adjuvant), injected subcutaneously (s.c.) near spinal vertebrae. In the validation study with fingolimod, we have demonstrated the modulation of disease symptoms, which were also confirmed by histopathological evaluation. Furthermore, detailed validation with three other known drugs showed that our observations concur with those reported in conventional rodent models.


We have standardized and validated the adult zebrafish EAE model. This model can help get a quick idea of in vivo activity of drugs in a week using very low quantities of candidate compounds. Further work will be required to define this model particularly as it is found that zebrafish may not express a MOG homologue.

  • Zebrafish develop EAE
  • Zebrafish EAE is treated with MS DMT
  • You don't need to use mice, or larger animals, to look for Immunosuppressive treatments
  • Another nail in the rodent EAE coffin?
  • If this work is true, and it needs to be repeated, the authors lucked out

As anyone who works on animals in the EU, you are committed to consider the 3Rs (refinement, reduction replacement) of animals in research. 

People take the argument for using mice because there is no other less sentient animal to do the study.

This rug is being pulled from under the carpet and if this work proves to be true, it could set the cat amongst the pigeons.

Zebrafish are one of the model organisms that people use because the offspring are transparent and you can make transgenic ,gene-altered fish. There are quite a few myelination projects going on in these fish.

However, this study says you can get EAE in fish, by immunizing them with myelin peptides just like you would do in a mouse.

Is this the end of mouse EAE,. Maybe if the ethics committee eat this study up.

However, is it true?

It will be repeated and I guess this will be starting today or tomorrow being monday

The authors started by injecting myelin oligodendrocyte glycoprotein (MOG) in adjuvant to induce a paralytic disease.  So far so good but as the fish do not produce MOG, how can this occur? There is no target to be attacked by the immune system.

Next they used fingolimod, which traps T (& B) cells in lymph glands so they can't get in the blood so thet can't get in the brain. However, fish don't have lmyph glands, but fingolimod blocks the EAE. How can that be?

The study "smells fishy"

This could mean it is all tosh, but maybe it is a lucky study.

The simple solution is for someone else to repeat it, but this takes fishy studies into a new level of ethics

Studies in the mouse report that immune responses to the MOG peptide can cross react with a immune responses to a nerve protein to induce the disease? Does this operate here? We don't know because there were no T cell responses measured.

This will mean repeating the work, but this may be another signal for killing off those EAE, that are justified in the name of MS research, that have so little real relevance.

I get that bad Home office (Animal Inspectors) feeling coming .

Saturday, 21 January 2017

#ResearchSpeak: it's the B-cells again

How soon will it be before we can clear the MS brain of plasma cells? Not soon enough. #ResearchSpeak #MSBlog

The study below confirms what we already know that even early in the course of MS B-cells and plasma cells are up to no good. Gray matter, or cortical, atrophy correlates with an inflammatory chemokine (CXCL13) responsible for attracting B-cells into the CNS. 

Interestingly, the authors interpret the lower BAFF (a B-cell survival and growth factor) to indicate that it must be plasma cells that have entered the CNS from the periphery and not matured centrally. I don't agree with this interpretation, what is the evidence for this? If it was the case then peripheral clones would result in matched OCBs. In the MS the majority of OCBs are unmatched, in other words are due to local synthesis. Surely the low BAFF levels could be due to local consumption? 

Despite these subtleties in relation to the interpretation of the data this study suggest that intrathecal B-cell and their products are associated with gray matter atrophy; this is part of the brain that is responsible for cognition. If this is the case we will need to clear the CNS of pathogenic B-cells and plasma cells if we want to prevent long-term damage from occurring. This is why anti-CD20 therapies may not be good enough to prevent delayed worsening of MS. If you haven't read our previous posts on this you may find the most recent one on rituximab failing to prevent delayed worsening or in the old terminology non-relapsing SPMS.  

The intrathecal plasma cell; is this the new enemy from within?

Puthenparampil et al. BAFF Index and CXCL13 levels in the cerebrospinal fluid associate respectively with intrathecal IgG synthesis and cortical atrophy in multiple sclerosis at clinical onset. J Neuroinflammation. 2017 Jan 17;14(1):11. doi: 10.1186/s12974-016-0785-2.

BACKGROUND: B lymphocytes are thought to play a relevant role in multiple sclerosis (MS) pathology. The in vivo analysis of intrathecally produced B cell-related cytokines may help to clarify the mechanisms of B cell recruitment and immunoglobulin production within the central nervous system (CNS) in MS.

METHODS: Paired cerebrospinal fluid (CSF) and serum specimens from 40 clinically isolated syndrome suggestive of MS or early-onset relapsing-remitting MS patients (CIS/eRRMS) and 17 healthy controls (HC) were analyzed for the intrathecal synthesis of IgG (quantitative formulae and IgG oligoclonal bands, IgGOB), CXCL13, BAFF, and IL-21. 3D-FLAIR, 3D-DIR, and 3D-T1 MRI sequences were applied to evaluate white matter (WM) and gray matter (GM) lesions and global cortical thickness (gCTh).

RESULTS: Compared to HC, CIS/eRRMS having IgGOB (IgGOB+, 26 patients) had higher intrathecal IgG indexes (p < 0.01), lower values of BAFF Index (11.9 ± 6.1 vs 17.5 ± 5.2, p < 0.01), and higher CSF CXCL13 levels (27.7 ± 33.5 vs 0.9 ± 1.5, p < 0.005). In these patients, BAFF Index but not CSF CXCL13 levels inversely correlated with the intrathecal IgG synthesis (r > 0.5 and p < 0.05 for all correlations). CSF leukocyte counts were significantly higher in IgGOB+ compared to IgGOB- (p < 0.05) and HC (p < 0.01), and correlated to CSF CXCL13 concentrations (r 0.77, p < 0.001). The gCTh was significantly lower in patients with higher CSF CXCL13 levels (2.41 ± 0.1 vs 2.49 ± 0.1 mm, p < 0.05), while no difference in MRI parameters of WM and GM pathology was observed between IgGOB+ and IgGOB-.

CONCLUSIONS: The intrathecal IgG synthesis inversely correlated with BAFF Index and showed no correlation with CSF CXCL13. These findings seem to indicate that intrathecally synthesized IgG are produced by long-term PCs that have entered the CNS from the peripheral blood, rather than produced by PCs developed in the meningeal follicle-like structures (FLS). In this study, CXCL13 identifies a subgroup of MS patients characterized by higher leukocyte counts in the CSF and early evidence of cortical thinning, further suggesting a role for this chemokine as a possible marker of disease severity.

Fingolimod blocking Alemtuzumab action what does it tell us about MS?

Willis M, Pearson O, Illes Z, Sejbaek T, Nielsen C, Duddy M, Petheram K, van Munster C, Killestein J, Malmeström C, Tallantyre E, Robertson N. An observational study of alemtuzumab following fingolimod for multiple sclerosis. Neurol Neuroimmunol Neuroinflamm. 2017 Jan 10;4(2):e320.

OBJECTIVE:To describe a series of patients with relapsing multiple sclerosis (MS) who experienced significant and unexpected disease activity within the first 12 months after switching from fingolimod to alemtuzumab.
METHODS:Patients with relapsing MS treated sequentially with fingolimod then alemtuzumab who experienced significant subsequent disease activity were identified by personal communication with 6 different European neuroscience centers.
RESULTS:Nine patients were identified. Median disease duration to alemtuzumab treatment was 94 (39-215) months and follow-up from time of first alemtuzumab cycle 20 (14-21) months. Following first alemtuzumab infusion cycle, 8 patients were identified by at least 1 clinical relapse and radiologic disease activity and 1 by significant radiologic disease activity alone.
CONCLUSIONS:We acknowledge the potential for ascertainment bias; however, these cases may illustrate an important cause of reduced efficacy of alemtuzumab in a vulnerable group of patients with MS most in need of disease control. We suggest that significant and unexpected subsequent disease activity after alemtuzumab induction results from prolonged sequestration of autoreactive lymphocytes following fingolimod withdrawal, allowing these cells to be concealed from the usual biological effect of alemtuzumab. Subsequent lymphocyte egress then provokes disease reactivation. Further animal studies and clinical trials are required to confirm these phenomena and in the meantime careful consideration should be given to mode of action of individual therapies and sequential treatment effects in MS when designing personalized treatment regimens.
If the observation is correct and not a statistical artefact, it must be telling us something about MS.
We all know that alemtzumab is a pretty effective drug at blocking relapsing MS. Likewise fingolimod is pretty effective at blocking MS. However, when alemtuzmab was given following fingolimod, then it looks like alemtuzumab is not working. Why?

Alemtuzumab was started before fingolimod was washed-out and so the disease forming cells are trapped in the lymph glands. Therefore they can't be destroyed by the alemtuzumab, so once fingolimod wears off, cells go back into blood and off MS goes.

First what does fingolimod do?
We have been through this before

Fingolimod is a sphingosine-1-phosphate one (S1P1) receptor modulator and when it binds to its target the receptor is down regulated. As S1P1 is involved in lymphocytes exiting the lymph glands require both S1P1 and a a chemokine receptor. It traps certain types of white blood cell in the lymph glands so they can't get into the blood and they can't get into the brain and so stop disease.

Adaptive immunity depends on regular circulation of lymphocytes between blood and lymphoid tissue in the search for antigens.
When an activating antigen is encountered in the lymph nodes, T cells are retained in the lymph node where naïve T cells become activated and central memory T cells (TCM) are reactivated. Following activation, these T cells return to the blood circulation, allowing them to reach sites of inflammation. 

These cells express CD62L which helps them to traffic into lymph glands via specialised blood vessels called high endothelial cell venules.

Fingolimod does not affect all cells but blocks exit of naive and central memory cells but not effector memory cells. The memory T cell pool functions as a dynamic repository of antigen-experienced T lymphocytes that accumulate over the lifetime of the individual. 

Recent studies indicate that memory T lymphocytes contain distinct populations of central memory (TCM) and effector memory (TEM) cells characterized by distinct homing capacity and effector function. 

This would imply that the disease causing cell is not in the TEM population as fingolimod does not block their movement of cells but blocks relapse. 

The percentages of naïve T cells and TCM in peripheral blood were significantly reduced in patients treated with fingolimod compared with untreated patients, and consequently the percentages of TEM in peripheral blood increased significantly in fingolimod-treated patients compared with untreated patients. While fingolimod reduced the numbers of both CD4+ and CD8+ T cells, the effect was more pronounced for the CD4+ T-cell subset.

We all know that naive T cells would not be the cause of autoimmunity, as they havent been sensitized to a target yet, so that would leave the TCM. Howver we know that CD62L are not the cells entering the CNS.

Fingolimod also blocks B cells entering the blood. These can come from lymph glands but also come from the spleen and fingolimod traps T and B cells in the bone marrow, where numbers go up.

Maeda Y, Seki N, Sato N, Sugahara K, Chiba K. Sphingosine 1-phosphate receptor type 1 regulates egress of mature T cells from mouse bone marrow. Int Immunol. 2010; 22(6):515-25.

Although fingolimod is taken every day, it is eliminated from the system quite slowly, notably because it accumulates in the fat in the brain and elsewhere. 

Once you stop fingolimod, relapses can occur within 1-4 months so it may take a few weeks to a couple of months before cells exit the lymph glands.

How does alemtuzumab work or not work

Alemtuzumab is a lymphocyte depleting antibody and destroys T and B cells. However , you may not know is how it kills white blood cells.

Antibodies can kill by complement fixation. This means that a cascade of small complement proteins are made and these serve to form a membrane attack complex that punches holes in cells. They cause the damaged cells to then liberate their contents and die.

Another way is antibody-dependent cellular cytoxicity

In this case the antibody binds to its target. The antibody is bound by a phagocytic cell by Fc receptors binding to the end of the antibody called the Fc region. The phagocytic cell then attacks and kills the target.

So if we look in a mouse with human CD52 injected with alemtuzumab

Investigation of the mechanism of action of alemtuzumab in a human CD52 transgenic mouse model. Hu Y, Turner MJ, Shields J, Gale MS, Hutto E, Roberts BL, Siders WM, Kaplan JM. Immunology. 2009;128(2):260-70.

If you remove complement (with cobra venon toxin) it has no impact on killing of T (CD4 or CD8) or B cells (CD19) in the blood or the spleen. However if you deplete neutrophils (phagocytic white cell) or natural killer cells which are the ADCC killing mechanism then you don't kill cells.

This is important because whilst you have loads of neutrophils and natural killer cells in the blood you have many fewer in the lmyphoid tissues such as lymph glands and bone marrow.

So whilst alemtuzumab may be good at depleting cells in the blood it will be less effective at killing cells in the lymph glands and bone marrow. Indeed this can be seen above. So whilst you can see that alemtuzumab kills about 90% of CD4 cells in the blood but only 75% in the spleen.

If you look at the depletion in different tissues, it is not too bad in the lymph glands but much less effective in the spleen and bone marrow

So whilst alemtuzumab can clear the blood it may be less good at clearing lymph glands and definately not too good at clearing the bone marrow.

In humans, alemtuzumab is largely gone from circulation within about 2 weeks after infusion.

So if the disease causing cells are sequested in lymphoid tissue for more time than this, then they won't get depleted and then once the fingolimod wears off they enter the circulation again.

Whilst a lot of emphasis is placed on fingolimod acting in lymph glands, alemtuzumab is not that bad at depleting T cells in lymph glands.

However in lymph glands, we and others have found that B cells are less sensitive to depletion than T cells.

Therefore there is relative saving of B cells in the lymph node. In the picture below you can see the cortex and follicles (B cell area black arrow). However the paracortex (T cell area blue arrow) is abit less dense (on right alemtuzumab treated) with low dose alemtuzumab in mice. So the T cells are preferentially being cleared.

Hu et al. 2009

We showed that B cells are depleted even less than T cells notably in the lymphoid tissue compared to blood.

Depletion of CD52-positive cells inhibits the development of central nervous system autoimmune disease, but deletes an immune-tolerance promoting CD8 T-cell population. Implications for secondary autoimmunity of alemtuzumab in multiple sclerosis. von Kutzleben S, Pryce G, Giovannoni G, Baker D.
Immunology. 2016 Dec 7. doi: 10.1111/imm.12696. [Epub ahead of print]

This was shown by others too

Immune status following alemtuzumab treatment in human CD52 transgenic mice. Turner MJ, Lamorte MJ, Chretien N, Havari E, Roberts BL, Kaplan JM, Siders WM. J Neuroimmunol. 2013 Aug 15;261(1-2):29-36.

So B cells are depleted less than T cells and they recover faster, probably because alemtuzumab does not deplete in the bone marrow or lymphoid tissues very well.

Did you know?

Rituximab and ocreliziumab depletes B cells, so has this effect been seen after fingolimod treatment?  It has not been reported yet

Ocrelizumab depletes via ADCC and so one wonders if it's action could be blocked by fingolimod similar to alemtuzumab. So be warned.

But as it is not approved there has not enough time to use it as a switching antibody. But an interesting experiment.

Rituximab depletes via complement and may be better at purging bone marrow cells. 

However as B cell depletion is maintained by 6 monthly dosing so if MS is B cell-mediated, disease won't return, if it is T cell-mediated is could...No reports of this yet. 

So does it point the finger at B cells as the important target in MS?
Is this telling us that MS is a T cell disease or is it all due to B cells?

What does MrT think?

If we did the experiment in the beasties it would be T cells, but in MS?


However, if you are taking fingolimod and need to switch, you need to talk this through before quickly switching to a depletion treatment antibody.

DrK will say even more reason to get a chemical depleter like cladribine back on the table as a small molecule is going to get into those Nocks and Crannies that antibodies like alemtuzumab won't...tick tock, tick, tock.

This rebound will not occur in every body. In this study
there were 36 six people, who had used fingolimod before alemtuzumab and the disease activity was seen in 9 people i.e. 25%. Remember, alemtuzumab is not infallible and relapse (4% in the cardiff cohort) in the first year occurs.

Of these people 8/9 were disease free after the second set of infusions