Scientists, clinicians and health care professionals from around the world gathered virtually on September 11-13 to participate in the 8th ACTRIMS (Americas Committee for Treatment and Research in MS) and ECTRIMS (European Committee for Treatment and Research in MS) joint meeting. This year, the conference was delivered in a virtual format (MSVirtual2020) which included over 50 scientific sessions, 1,100 e-poster presentations, 23 teaching courses, along with virtual exhibition and networking opportunities. The complete program guide can be found here. Below are highlights of select lectures and platform presentations from MSVirtual2020.
Updates on MS causes and risk factors:
MS Society funded researcher and University of British Columbia professor, Dr. Helen Tremlett, kicked off the conference by presenting a plenary lecture on the MS prodrome. Dr. Tremlett reviewed clinical and epidemiological evidence that the MS disease process can begin years before patients experience their first demyelinating episode. She indicated that people diagnosed with MS were up to 50% more likely to visit a physician or hospital for conditions including mental health, migraine headaches, dermatological issues, sleep disturbance, hormonal issues, irritable bowel syndrome, etc. This observation has important implications for MS diagnosis and clinical care. Recognizing the clinical features of the MS prodrome presents an opportunity for early disease detection and intervention. To learn more about the MS prodrome, read our latest MS update here.
Obesity and metabolic syndrome
Dr. Ruth Ann Marrie of the University of Manitoba introduced the subject of Metabolic Syndrome (MetS) in MS. MetS is defined by hypertension, obesity, dyslipidemia (abnormal amount of lipids in blood) and elevated blood glucose; a key component of which is visceral obesity, often measured by waist circumference. Dr. Marrie discussed the correlation between MetS and the effect on MS, some of which include diagnostic delays, accelerated disability progression and increases in relapse rate. As it is unclear whether the mechanisms and effects of MetS are general or disease specific, additional clinical research is needed to determine whether treating MetS can also alleviate symptoms of MS.
Environmental exposures and MS risk
Harvard research scientist, Dr. Kassandra Munger, evaluated the correlations of Epstein Bar Virus (EBV) and Vitamin D levels with MS risk. Her analysis of current literature strongly suggests that EBV is a likely cause of MS. Dr. Munger and team measured EBV antibody titers in military populations and found that higher levels of antibodies were associated with an increased risk of MS. She additionally measured vitamin D levels and found a 50-60% reduced risk of MS when levels were greater than 75 nmol/L. Despite these correlations, Dr. Munger cautioned that these findings may be subject to reverse causation (there may be a sub-clinical disease that affects vitamin D), recall bias in case-control studies, and the possibility of confounding factors. Furthermore, when applying the Bradford Hill criteria for determining cause and effect, Dr. Munger made the argument that EBV is a much more likely cause of MS compared to vitamin D status.
Updates on the clinical management of MS:
Escalation vs Induction Therapy
Dr. Ellen Mowry of the Johns Hopkins School of Medicine talked about the growing need to better define how to select the most appropriate treatment for individual MS patients. The literature has shown at least two treatment strategies: i) Induction Therapy, where higher-efficacy medication is used as the first treatment option, and ii) Escalation Therapy, where patients who have breakthrough disease are switched from an initial moderate-efficacy medication to higher-efficacy therapy. There is currently no definitive data to support either approach, thus two clinical trials have been developed to investigate which treatment strategy is more effective in preventing long-term disability among MS patients. TREAT-MS (TRaditional versus Early Aggressive Therapy for MS) is an ongoing trial across 45 sites in the United States. DELIVER-MS (Determining the Effectiveness of earLy Intensive Versus Escalation approaches for RRMS) is currently performed across 24 centres in the UK and USA.
Perspectives from MS Nurses
The International Organization of MS Nurses organized a special session which included talks on advanced MS nursing activities. This year, the session emphasized on patient-centred experience of care. Megan Weigel, a Nurse Practitioner from First Coast Integrative Medicine, investigated the use of integrative medicine as an option for MS treatment. She talked about an approach that combines conventional (data driven) and alternative medicine (such as natural products, massage and diets) that is safe and patient focused.
Jennifer Boyd, a Clinical Nurse Specialist from the Hospital for Sick Children, evaluated the specific type of care required to treat pediatric patients with MS. She emphasized the value of communicating appropriately, which can change and adjust according to the patient’s level of development or adolescent issues (such as concerns about feeling different). The key is to ensure that both children and parents are educated and supported throughout the process.
Updates on progressive MS:
Disease modifying therapies for progressive MS
An overview of the evolving therapeutic landscape for progressive MS was presented by Dr. Xavier Montalban of the MS Centre of Catalonia in Barcelona, Spain. To date, ocrelizumab is the only disease-modifying therapy approved for the treatment of primary progressive MS. As the update provided at ACTRIMS/ECTRIMS included activities outside of Canada, other countries have included the indication of active secondary progressive MS for ocrelizumab, siponimod, cladribine, ofatumumab and ozanimod. In Canada, treatment options for active secondary progressive MS include select interferon formulations and more recently, siponimod (approved) and ofatumumab (pending Health Canada decision). In addition, clinical trials are ongoing for drugs such as lipoic acid, simvastatin, and ibudilast to assess their efficacy and potential use in progressive MS. More research is needed to understand the pathogenic mechanisms of progressive MS and further develop promising therapeutic options.
Remyelination is important in preventing neurodegeneration and MS disease progression. Cells known as oligodendrocytes are involved in the remyelination process and they require prior activation and maturation. Dr. Robin Franklin, professor at the University of Cambridge, discussed how aging can affect the nerve cell’s ability to promote remyelination naturally. He indicated that an aged brain appears more stiff to oligodendrocytes and impairs their ability to mature. Interestingly, several effective strategies have been developed to reverse the effects of aging, including calorie restriction and the use of the anti-diabetic drug metformin.
Dr. Catherine Lubetzki of the Hôpital Pitié-Salpêtrière also presented an excellent summary of current strategies to promote remyelination. At the pre-clinical stage, Dr. Lubetzki’s research group has identified a molecule called Semaphorin 3F (Sema3f) that has shown potential in enhancing the rates of remyelination at lesion sites of MS mouse models. At the clinical stage, there are multiple compounds being investigated for their ability to target specific pathways that either inhibit (i.e. histamine H3 receptor, Lingo1, muscarinic M1 receptor) or promote (retinoid X receptor gamma) oligodendrocyte maturation. In particular, Bexarotene was a subject of a recent Phase II clinical trial to assess its ability to act on the retinoid X receptor gamma and promote remyelination in people with MS. While the trial results confirmed that Bexarotene can promote remyelination within individual lesions, the drug’s side effects were too severe for clinical use.
For more information on ongoing clinical trials involving remyelination, see Dr. Lubetzki’s recent review article here.
Late Breaking Sessions:
On September 26, a special encore event was held to feature updates on COVID-19 and MS, along with other high-impact MS research. Dr. Steve Simpson-Yap of the University of Melbourne presented the first results of the COVID-19 & MS global data sharing Initiative. This initiative was assembled by the MS International Federation, MS Data Alliance, and other data partners to inform MS clinical management during the COVID-19 pandemic. In his presentation, Dr. Simpson-Yap indicated that older age, progressive MS, and higher disability are associated with higher frequencies of severe COVID-19 outcomes. The use of anti-CD20 disease-modifying therapies (ocrelizumab and rituximab) were also associated with hospital admission, ICU admission, and the need for artificial ventilation among COVID-19 patients with MS. These results suggest that the use of anti-CD20 medications may be a risk factor for more severe COVID-19 disease compared to other disease-modifying therapies.
Dr. Amber Salter, professor at the Washington University School of Medicine in St. Louis, also presented initial results from COViMS, which is the North American initiative that captures clinical information and outcomes of people with MS who have developed COVID-19. The initial analysis assessed COVID-19 outcomes in minority groups with MS. Data within the COViMS registry suggest that Black/African American MS patients were younger and more likely to have comorbidities (such as hypertension and morbid obesity) compared to White MS patients. Furthermore, Black MS patients showed an increased risk for poorer COVID-19 outcomes (such as mortality, ICU admission and/or hospitalization) compared to White MS patients. To learn more, read our latest MS update here.
These are just some of the late breaking and interesting research in MS.
Browse all research presented at MSVirtual2020 – here.