Monday, 24 October 2016

Getting the Right Models

Lassmann H, Bradl M.Multiple sclerosis: experimental models and reality. Acta Neuropathol. 2016 Oct 20. Review.

One of the most frequent statements, provided in different variations in the introduction of experimental studies on multiple sclerosis(MS), is that "Multiple sclerosis is a demyelinating autoimmune disease and experimental autoimmune encephalomyelitis (EAE) is a suitable model to study its pathogenesis". However, so far, no single experimental model covers the entire spectrum of the clinical, pathological, or immunological features of the disease. Many different models are available, which proved to be highly useful for studying different aspects of inflammation, demyelination, remyelination, and neurodegeneration in the central nervous system. However, the relevance of results from such models for MS pathogenesis has to be critically validated. Current EAE models are mainly based on inflammation, induced by auto-reactive CD4+ T-cells, and these models reflect important aspects of MS. However, pathological data and results from clinical trials in MS indicate that CD8+ T-cells and B-lymphocytes may play an important role in propagating inflammation and tissue damage in established MS. Viral models may reflect key features of MS-like inflammatory demyelination, but are difficult to use due to their very complex pathogenesis, involving direct virus-induced and immune-mediated mechanisms. Furthermore, evidence for a role of viruses in MS pathogenesis is indirect and limited, and an MS-specific virus infection has not been identified so far. Toxic models are highly useful to unravel mechanisms of de- and remyelination, but do not reflect other important aspects of MS pathology and pathogenesis. For all these reasons, it is important to select the right experimental model to answer specific questions in MS research.

We are at a time of animal bashing as there is not a model that has all elements of MS. That is true, but we have to remember that we can only model what you are told happens and here the pathology has much to answer. 

When I started my MS career it was written over and over again that MS was a disease of the white matter, but you just needed a pair of eyes to see that wasn't the case because you can see grey matter lesions with the naked eye.

Maybe the problem was the pathologists weren't doing the dissection, they maybe had technicians doing the work dissecting the brain, doing the sections and then staining with luxol fast blue, but because them pathologists siad there was no myelin in the grey matter the technicians would destain the sections until there was no stain in the grey matter and lesions missed. It was only when they started staining with antibdies that gey matter lesions were evident.
The imagers had missed this too because their machines could pick up lesions.

Then there is nerve loss has only become an issue when it was rediscovered in 1997/1998, but there was a long literature and agin using your eyes atrophy can be seen with the naked eye.

The problem is if you looked a group of pathologists in a room we would get the same answer of what are the pathological mechanisms occuring in MS.

What happens when you look weeks and months and years after the event. We know in EAE it looks very different. 

However the authors have a point because the models are driving ideas on potential therapies and there are powerful dogmas driving these choices. If the choices are based on false ideas then they are a based on a pack of cards....waiting to fall.

We are focusing on Th17 as a cause of MS....CD4 depletion has failed, blocking interleukin 17 has failed...(reducing lesion load by 50% is a failure). what's the evidence to support this in MS

What are the CD8 doing what makes them arrive. Surely the target must be in the CNS tissue they are attacking. If it is a virus it must be there...why have the not been found..have they been found as every cell has endogenous retro virus in its genome, in most cases live virus is not made.

Should we be depleting CD8 cells?.....would this be dangerous 
because CD8 cells have regulatory cells in their population

What are B cells doing, presenting antigen to T cells, what type of B cells are important? Depleting B cells can certainly work in MS

What is happening in areas distant from where the pathology is done, etc, etc etc. 

I've seen loads of reviews questioning animal work but essentially nothing questioning the pathology and the clinical work. It is bad for business because it is suggesting the neuros are fallible.

Baker D, Amor S.Experimental autoimmune encephalomyelitis is a good model of multiple sclerosis if used wisely. Mult Scler Relat Disord. 2014;3(5):555-64.

Baker D, Amor S. Mouse models of multiple sclerosis: lost in translation?Curr Pharm Des. 2015;21(18):2440-52

However ,we know this is true because we not finding enough useful treatments and as ProFG has said I think we have thrown away useful treatments. Not the stuff you want to hear, not the stuff that puts the academics in a good light.

I think that response to therapy tells us alot and there has to by clues in interogating this. 

Is it all EBV and an ant-virus response.

Sunday, 23 October 2016

#ClinicSpeak & #PoliticalSpeak: time for a revolution in the way we manage MS

With the NHS on its knees we need to innovate and change the way we manage MS. #ClinicSpeak #PoliticalSpeak #MSBlog

Last week at our Barts-MS Strategy day we heard that a very important, almost essential, business case had been turned down by our senior management team. We were simply asking for a new nursing post to help with our expanding MS service. The reason is that our NHS Trust (Barts Health) is in financial special measures; there are no funds to support any new service developments. This is despite our MS service being very profitable, in fact the most profitable service in our neuroscience cluster. This puts Barts-MS in a very difficult position and we now have to consider how we manage our future commitments to our patients going forward.

The financial constraints we are working under in the NHS are the worst in living memory and are putting us under considerable strain. Please see the excerpts below from a Guardian article, about Barts Health NHS Trust, that was published earlier this year.

We therefore had a short brain storming session on Thursday and we came to the conclusion that we are going to have to make fundamental changes to how our MS service works. We need to be radical. How do you as someone with MS feel about managing, and monitoring, your own disease and being helped by other people with MS?

We propose setting-up a Barts-MS Expert Patient Course during which we will teach you everything you need to know about MS, the management of MS and how to monitor and manage your own disease. We will then provide you with the tools to get on with it. The system we set-up will allow you to contact us if you run into problems and/or need help, for example with a specialist referral. We will hopefully allow you to self-refer for essential services, for example continence advise and therapy. We also will identify expert patients with MS who can help us run the teaching course and our service on a voluntary basis. It is our ambition to run, and coordinate, the largest self-management MS service in the country.

To kick-start this we will need some priming money to design, produce materials, run the course and pilot the self-management component of the service. We envisage the need to create an online self-management web app that will incur costs (design and tech input). As we won't be able to get any funding from our Trust for this new service, we propose running a crowd-funding campaign. To kick-start it we will need something in the order of £6,000-£10,000. Do you think a Barts-MS Self-Management Service is a good idea and do you think we should be raising money for the community to set it up? Desperate times requires outside the box thinking; we need to revolutionise the way we manage MS, and finding that we have been painted into a corner means we have to try something new and radical.

Denis Campbell. The Guardian London hospital trust heading for biggest overspend in NHS history. Sunday 7 February 2016  and Last modified on Tuesday 10 May 2016.


.... The biggest hospital trust in the country is set to run up a £134.9m deficit this year – by far the largest ever overspend in the history of the NHS.
..... Barts Health NHS Trust, which runs four hospitals in east London, employs 15,000 people and serves an area containing 2.5 million people, is on course to have failed to balance its books by that margin when the NHS financial year ends on 31 March. Its overspend is 69% bigger than the trust’s £79.6m overspend – also a record at the time – in 2014-15.

..... “These forecast deficits provide further evidence of the escalating financial crisis in the NHS, as well as the longstanding challenges facing London’s health system. In the case of Barts, these pressures have been exacerbated by the costs of a major PFI development,” said Prof Chris Ham, chief executive of the independent health thinktank, the King’s Fund.

..... Barts’s deficit may end up even bigger than £134.9m. At its board meeting last week, Chrisha Alagaratnam, the trust’s interim chief financial officer, disclosed that the deficit had already reached £115.6m by the end of November, “which represented a £24.4m adverse position against the financial plan”. That overshoot was due to it having made too few savings, received less income than expected and been fined for missing key NHS targets.

..... The sheer size of the deficits run up in the capital suggested that the £1.8bn of extra funding the NHS in England has been given for next year, which the health secretary, Jeremy Hunt, has earmarked to wipe out collective overspend by trusts may prove inadequate, added Ham. “The extra funding provided by the government is being used mainly to get the NHS back into financial balance but even this must be in doubt given the scale of the deficits now being reported. 2016/17 will be a make-or-break year for the NHS,” he said.

.... Alwen Williams, Barts’s chief executive, said that although its deficit was England’s biggest, the trust’s huge size and income meant it was no worse in relative terms than those of other trusts. Barts’s income is about £1.4bn a year, so its overspend represents about 10% of its budget.

..... “Since we are the biggest NHS trust in the country, it is not surprising we are forecasting the largest deficit, although as a proportion of turnover it is comparable to other acute trusts in England,” she said.

..... Nevertheless we are taking concerted steps to improve our financial position by improving the productivity of our four hospitals, working with commissioners to ensure that any money that might have been levied in fines and penalties is reinvested in the trust, and recruiting to permanent posts rather than using expensive agency staff.”

..... Reports presented at Barts’s board meeting last week showed that, of the £68m a month it spends on its workforce’s wages, £7m goes on agency staff. The trust has calculated about £30m of the £80m-a-year cost of agency staff is taken up by the premiums the staffing agencies charge.

..... Barts last year was fined £56m by local NHS organisations for failing to treat A&E patients within four hours and those waiting for planned care within 18 weeks. It is thought to be paying out even more in fines this year as pressure on NHS services has led to most trusts missing key targets.

.... In all, 18 of London’s 37 NHS Trusts are due to record a collective deficit of £582.3m, Burt disclosed. Senior NHS sources said that the fact that so many trusts cannot balance their books shows the NHS is receiving too little money to cope with rising demand, despite its budget having been ringfenced and growing in real terms.

..... GPs fear that hospitals will continue receiving so much extra cash to tackle their financial problems that their practices will not get the extra money – £2bn a year by 2020 – that Hunt has promised.

..... “The alarming size and scale of the deficits facing London’s hospital trusts means that any of the oft quoted extra money for GPs is unlikely to reach local practices or help improve access for patients. Instead, we will see commissioning bodies diverting funds from primary care to keep the lights on in the capital’s hospitals,” said Dr Michelle Drage, chief executive of Londonwide LMCs (local medical committees).

Alemtuzumab and the innate immune cells

Gross CC, Ahmetspahic D, Ruck T, Schulte-Mecklenbeck A, Schwarte K, J├Ârgens S, Scheu S, Windhagen S, Graefe B, Melzer N, Klotz L, Arolt V, Wiendl H, Meuth SG, Alferink J. Alemtuzumab treatment alters circulating innate immune cells in multiple sclerosis. Neurol Neuroimmunol Neuroinflamm. 2016 Oct 12;3(6):e289.

OBJECTIVE:To characterize changes in myeloid and lymphoid innate immune cells in patients with relapsing-remitting multiple sclerosis (MS) during a 6-month follow-up after alemtuzumab treatment.
METHODS:Circulating innate immune cells including myeloid cells and innate lymphoid cells (ILCs) were analyzed before and 6 and 12 months after onset of alemtuzumab treatment. Furthermore, a potential effect on granulocyte-macrophage colony-stimulating factor (GM-CSF) and interleukin (IL)-23 production by myeloid cells and natural killer (NK) cell cytolytic activity was determined.
RESULTS:In comparison to CD4+ T lymphocytes, myeloid and lymphoid innate cell subsets of patients with MS expressed significantly lower amounts of CD52 on their cell surface. Six months after CD52 depletion, numbers of circulating plasmacytoid dendritic cells (DCs) and conventional DCs were reduced compared to baseline. GM-CSF and IL-23 production in DCs remained unchanged. Within the ILC compartment, the subset of CD56bright NK cells specifically expanded under alemtuzumab treatment, but their cytolytic activity did not change.
CONCLUSIONS:Our findings demonstrate that 6 months after alemtuzumab treatment, specific DC subsets are reduced, while CD56bright NK cells expanded in patients with MS. Thus, alemtuzumab specifically restricts the DC compartment and expands the CD56bright NK cell subset with potential immunoregulatory properties in MS. We suggest that remodeling of the innate immune compartment may promote long-term efficacy of alemtuzumab and preserve immunocompetence in patients with MS.

This study looks at the effect of alemtuzumab on dendritic cells and natural killer cells at baseline and 6 and 12 months after alemtuzumab and finds that alemtuzumab-induced decrease of CD4+ T cells was accompanied by an increase in frequencies of the CD56bright NK cells subset.  The authors state "Secondary autoimmune diseases including Hashimoto thyroiditis are common adverse reactions following alemtuzumab therapy. Although the underlying mechanisms of autoimmunity following alemtuzumab therapy have not yet been resolved, one can speculate on the functional implication of CD56bright NK cells in this process".

I suspect it doesn't have a major impact. 

It came as a surprise to me that that the leucocyte subset analysis of the effects in the phase III trials were not published in the pivotal data set, or in a paper afterwards. The data just appeared as some meeting reports published in abstracts, but if you know where to look, you can find the data and there was limited effect on CD16, CD56 NK cells. This study is based on a few samples when hundreds were tested in the trials.

Maybe it highlights the problems of looking at subsets. 
Are we subsetted enough?  To get the real picutre. 

As the CD56bright go up, the dim sort of go down. So looking just at positive may miss an effect.

The CD56 bright subset is expanded after daclizumab which inhibits MS 

However, people on daclizumab appear to get autoimmunity but these tend to be related to skin conditions rather than thyroid autoimmunity and so I suspect have a different origin. After dacliziumab the T regulatory population do down. Is this the problem? 

Safety and Efficacy of daclizumab

For alemtuzumab a cause because of T reg cells has been dismessed and it has been suggested that the autoimmunity after alemtuzumab is occuring because T cells do not repopulate via the thymus. 

I think there are other ideas too..but thats another story.

laquinimod blocking experimental progression

Varrin-Doyer M, Pekarek KL, Spencer CM, Bernard CC, Sobel RA, Cree BA, Schulze-Topphoff U, Zamvil SS. Treatment of spontaneous EAE by laquinimod reduces Tfh, B cell aggregates, and disease progression. Neurol Neuroimmunol Neuroinflamm. 2016 Sep 21;3(5):e272.


To evaluate the influence of oral laquinimod, a candidate multiple sclerosis (MS) treatment, on induction of T follicular helper cells, development of meningeal B cell aggregates, and clinical disease in a spontaneous B cell-dependent MS model.


Experimental autoimmune encephalomyelitis (EAE) was induced in C57BL/6 mice by immunization with recombinant myelin oligodendrocyte glycoprotein (rMOG) protein. Spontaneous EAE was evaluated in C57BL/6 MOG p35-55-specific T cell receptor transgenic (2D2) × MOG-specific immunoglobulin (Ig)H-chain knock-in (IgHMOG-ki [Th]) mice. Laquinimod was administered orally. T cell and B cell populations were examined by flow cytometry and immunohistochemistry.


Oral laquinimod treatment (1) reduced CD11c+CD4+ dendritic cells, (2) inhibited expansion of PD-1+CXCR5+BCL6+ T follicular helper and interleukin (IL)-21-producing activated CD4+CD44+ T cells, (3) suppressed B cell CD40 expression, (4) diminished formation of Fas+GL7+ germinal center B cells, and (5) inhibited development of MOG-specific IgG. Laquinimod treatment not only prevented rMOG-induced EAE, but also inhibited development of spontaneous EAE and the formation of meningeal B cell aggregates. Disability progression was prevented when laquinimod treatment was initiated after mice developed paralysis. Treatment of spontaneous EAE with laquinimod was also associated with increases in CD4+CD25hiFoxp3+ and CD4+CD25+IL-10+ regulatory T cells.


Our observations that laquinimod modulates myelin antigen-specific B cell immune responses and suppresses both development of meningeal B cell aggregates and disability progression in spontaneous EAE should provide insight regarding the potential application of laquinimod to MS treatment. Results of this investigation demonstrate how the 2D2 × Th spontaneous EAE model can be used successfully for preclinical evaluation of a candidate MS treatment.

This was lauched by accident yesterday, but as i posted it I suppose I should discuss it. I was not going to do this. Laquinimod has been tested to see if it can block relapsing MS and it was pretty poor, and in the same league as beta interferons. In this study the dose selected completely wipes out the disease in animals, so there is a disparity there. However the big issue in MS is that it appears that laquinimoid improved the loss of nerve content. to a much greater extent than would be predicted by an effect on relapses. So they did a trial and unfortunately a safety issue of the higher doses became apparent and bits of the trials were stopped. Studies on the lower dose continue.

This study was on mice and the drug can wipe the disease out unlike that occuring MS. They use a spontaneous model of MS and the drug is inhibitory, but does this model reflect progressive MS and the answer in my mind is no, it is simply an immune-disease model, Now it has been suggested that progressive MS is mediated by the activity of B cell and B cell follicles but the B cell aggregates seen in the animal models do not appear to have the real structure of a B cell follicle as shown in hte pictures, but laquinmod can sort them out. Does this mean it will block progresive MS. We have to wait and see. You can read the papers as it is open access...also read what the reviewers had to say.

Forsthuber TG, Stuve O.Neurol Neuroimmunol Neuroinflamm. 2016 Sep 21;3(5):e283

There was other animal studies presented at ECTRIMS/ISNI showing a model of nerve loss after dysmyelination that was not dependent on the immune T and B immune system and this wa sblocked by laquinimod , That was much mre impressive

Saturday, 22 October 2016

#ClinicSpeak & #ResearchSpeak: time to step-up or shut-up

Why did we allow the baby to be thrown-out with the bathwater? Successful, but unsuccessful, treatments for progressive MS. #ClinicSpeak #ResearchSpeak

There are so many killjoys out there who think progressive MS is an intractable problem and that we have no treatments that work. Incorrect! I would like to remind these killjoys of the cyclosporine and methotrexate studies from over 25 years ago in people with chronic progressive MS (SP & PPMS). Both these studies were positive and had an impact on disability progression. Cyclosporine was dropped because of renal toxicity and hypertension and methotrexate was dropped because most people think that protecting the upper limbs in people with progressive MS is not worth doing. 

I suspect, however, if methotrexate had been a innovative compound with a long patent-life it would have been taken forward into larger and more definitive trials. If these trials were done with modern insights we would have had a licensed DMT for progressive MS decades ago. What killed methotrexate as a treatment for MS was that it was a cheap generic drug. It is because of the trial below that I have included methotrexate on our essential off-label list of DMTs. If you had progressive MS would you consider methotrexate?  

The problem is that most pwMS and their families, and some in the neurological community, have unrealistic expectations of what to expect from an effective DMT for progressive MS. An anti-inflammatory therapy is unlikely to stop progression immediately, as this has been primed by previous damage and is destined to run its course over the next few years. What is more likely to occur is the slowing, or flat-lining, of progression over 2-5 year period; this delayed effect is what we refer to as therapeutic lag. The more neuronal reserve you have, i.e. the ability to recover function, the sooner you notice a therapeutic effect. 

With the natalizumab in SPMS, or ASCEND, trial there was no impact on EDSS and T25FW in 2 years, but a significant effect on the 9HPT. I suspect that if the trial went on longer for say 3 years then the EDSS and T25FW curves would have opened-up and we would have had a positive trial. There is a chance we may find-out if this actually happened; a large number of the original ASCEND population got to 3-years in the follow-up study of ASCEND before Biogen stopped the extension study. I predict that the study subjects who received natalizumab throughout the study (2 years of blinded study and one year of extension) will do better than those who were on placebo (2 years placebo and 1 year natalizumab). If I was a betting man I would put money down on this prediction.

The above is water under the bridge, right now we should be celebrating the recent results of ocrelizumab in PPMS and siponimod in SPMS, results. The killjoys say these results are not good enough. What do you want? Please remember a  25% difference in progression rates at 
at 2-3 years of follow-up may be 50% at 5 years and 75% at 10 years. I agree that if you have progressive MS these results are not what you want; you want to get back to normal. However, these drugs are not designed to restore function; for that to occur we need new therapies to add-on to anti-inflammatory therapies. Please be positive and celebrate the recent successes in progressive MS. The tragedy is we had similar successes over 25 years ago and we didn't build on them. This time we need to seize the day; carpe diem!

The Multiple Sclerosis Study Group. Efficacy and toxicity of cyclosporine in chronic progressive multiple sclerosis: a randomized, double-blinded, placebo-controlled clinical trial. Ann Neurol. 1990 Jun;27(6):591-605.

Methods: Patients with clinically definite multiple sclerosis, mild to moderately severe neurological disability (entry score on the Expanded Disability Status Scale (EDSS) between 3.0 and 7.0), and a progressive course defined by an increase in the EDSS of between 1 and 3 grades in the year prior to entry were randomized to receive either cyclosporine (n = 273) or placebo (n = 274) in a 2-year, double-blinded, multicenter trial. Treatment groups at entry proved balanced for age, gender, duration of illness, and neurological disability. Cyclosporine dosage was adjusted for toxicity and a median trough whole-blood level was maintained between 310 and 430 ng/ml. 

Results: The mean increase in EDSS score was 0.39 +/- 1.07 grades for cyclosporine-treated patients and 0.65 +/- 1.08 grades for placebo-treated patients from entry until the time of early withdrawal or completion of the study (p = 0.002). Of three primary efficacy criteria, cyclosporine delayed the time to becoming wheelchair bound (p = 0.038; relative risk, 0.765), but statistically significant effects were not observed for "time to sustained progression" or on a composite score of "activities of daily living." Active treatment did have a favorable effect on several secondary measures of disease outcome. A large and differential withdrawal rate (44% for cyclosporine-treated patients, 32% for placebo-treated patients) complicated the analysis but did not appear to explain the observed effect of cyclosporine in delaying disease progression. Multivariate analysis did not show institutional effects but did demonstrate substantial effects of baseline neurological disability on outcome. Nephrotoxicity and hypertension were common troublesome toxicities and accounted for most of the excess loss of patients in the cyclosporine arm of the study. 

Conclusion: Thus, chronic cyclosporine therapy was associated with a statistically significant but clinically modest delay of progression of disability in a group of patients with multiple sclerosis selected for moderately severe and progressive disease. Close supervision by physicians familiar with cyclosporine is mandatory to minimize known adverse effects, particularly nephrotoxicity, when considering the use of this immunosuppressant. 

Goodkin et al. Low-dose (7.5 mg) oral methotrexate reduces the rate of progression in chronic progressive multiple sclerosis.  Ann Neurol. 1995 Jan;37(1):30-40.

Methods: A randomized, double-blinded, placebo-controlled, clinical trial of low-dose, weekly, oral methotrexate was performed in 60 patients with clinically definite chronic progressive multiple sclerosis (MS) attending a referral-based outpatient MS clinic. Study patients were 21 to 60 years old with a disease duration of longer than 1 year. Patients' Expanded Disability Status Scale scores were 3.0 to 6.5 (ambulatory with moderate disability). Patients were first stratified by Expanded Disability Status Scale scores, 3.0 to 5.5 and 6.0 to 6.5, and then were randomized to receive methotrexate or placebo treatment. Treatment consisted of weekly, oral, low-dose (7.5 mg) methotrexate or identical placebo for 2 years, followed by observation for as long as 1 year. A composite outcome measurement instrument was used and consisted of (1) Expanded Disability Status Scale, (2) ambulation index, (3) Box and Block Test, and (4) 9-Hole Peg Test. 

Results: Failure of therapy was indicated by a designated change that was sustained for more than 2 months in one or more components of this composite measure. Significantly less progression of impairment as measured by validated tests of upper-extremity function was observed in the methotrexate treatment group in the absence of clinically significant toxicity

Conclusions: We conclude that low-dose, weekly, oral methotrexate offers a new, relatively nontoxic treatment option for patients with chronic progressive MS.

CoI: multiple