Update in body fluid markers
Gavin Giovannoni
Barts and The London School of Medicine and Dentistry
Why MS biomarkers?
• Diagnostic testing
– Positive & negative predictive testing
• Pathogenesis
– Immunology
– Aetiology
– Disease progression & recovery
– Disease heterogeneity
• Pharmacovigilance
• Monitor disease processes
– Prognosis (high vs. low risk patients)
– Monitoring effect of therapeutic interventions
Diagnostic & pathogenic markers
The evolving clinical definition of MS
1. Schumacher, et al. Problems of Experimental Trials of Therapy in Multiple Sclerosis: Report
by the Panel on the Evaluation of Experimental Trials of Therapy in Multiple Sclerosis. Ann N
Y Acad Sci 1965;122:552-68.
2. Poser, et al. New diagnostic criteria for multiple sclerosis: guidelines for research protocols.
Ann Neurol 1983;13:227-31.
3. McDonald, et al. Recommended diagnostic criteria for multiple sclerosis: guidelines from
the International Panel on the diagnosis of multiple sclerosis. Ann Neurol 2001;50:121-7.
4. Polman, et al. Diagnostic criteria for multiple sclerosis: 2005 revisions to the "McDonald
Criteria". Ann Neurol 2005;58:840-6.
5. Polman, et al. Diagnostic criteria for multiple sclerosis: 2010 revisions to the McDonald
criteria. Ann Neurol. 2011;69:292-302.
Will Rogers Phenomenon in Multiple Sclerosis
1879 - 1935
“When the Okies left Oklahoma and moved to California, they raised the average intelligence level in both states.”
Will Rogers Phenomenon in Multiple Sclerosis
Sormani et al. Ann Neurol 2008;64:428–433.
Poser
McDonald
Intrathecal synthesis of IgG
Images courtesy of Alastair Compston and Ed Thompson.
Kabat et al. J Clin Invest. 1942 Sep;21(5):571-7.
Carl Lange – Colloidal Gold Curve
Isoelectric focusing with immunfixation
Diagnostic criteria for Primary Progressive MS
Polman et al. Ann Neurol 2005;58:840-6.
Accumulation of disability in PPMS: stratified by intrathecal IgG abnormalities
Proportion Progressing as Percent
Epoch CSF- CSF+
6 mo 7.3 9.8
12 mo 15.0 20.4
18 mo 22.8 28.1
24 mo 25.4 34.3
Years to Progression
2.43 2.26
Based on data from a second meeting of the DSMB and assume no therapeutic effect
0 1 2 3 Years
0.0
0.2
0.4
0.6
0.8
1.0
Pro
po
rtio
n P
rogr
essi
ng
Positive Negative
CSF
Slide courtesy of Jerry Wolinsky
P =0.03
CSF oligoclonal bands in multiple sclerosis and clinically isolated syndromes: a meta-analysis of prevalence, prognosis and effect of latitude
Dobson et al. JNNP; in press.
Pharmacovigilance markers
Take special care with Interferon-beta-1b: If you might have a disorder of the immune system in which abnormal proteins are found in the blood (monoclonal gammopathy), you must check this with your doctor before you use interferon beta-1b. Patients who have the rare condition known as monoclonal gammopathy may develop problems with their small blood vessels (capillaries) leading to shock (collapse) which can be fatal, when they use medicines like interferon-beta-1b. See also 4. Possible side effects.
Natalizumab
Progressive multifocal leukoencephalopathy (PML)
Kleinschmidt-DeMasters,et al. N Engl J Med. 2005 Jul 28;353(4):369-74.
312 cases -5th December 2012 69 (22%) died 243 (78%) alive
Mild disability – 10% Moderate disability – 50% Severe disability – 40%
5% NAbs – infusion reactions
Natalizumab PML risk stratification tool
Mitoxantrone
Azathioprine
Methotrexate
Cyclophosphamide
Mycophenolate
Cladribine
Rituximab
Etc.
Anti-JCV Antibody Status
Negative Positive
Prior Immunosuppressant
Use
Natalizumab Treatment
>2 Years
Natalizumab Treatment
>2 Years
No Yes
No Yes No Yes
Lowest Highest
Relative PML Risk
1 in 14,285 1 in 1,666 1 in 192 1 in 94 1 in 555
Highest Lowest
Neurology 2012;78(Suppl.): [S41.006]
Predicting autoimmunity following treatment of MS with alemtuzumab
• 30% of alemtuzumab-treated pts develop autoimmune side-effects (primarily thyroid disease and idiopathic thrombocytopenia)
• Aim: To define predictive factors for autoimmune side-effects
• Sera of 141 pts screened at baseline for 8 different cytokines/chemokines
A combined IL-21/IL-7 test on pre-treatment serum may be useful to identify patients at low risk of developing autoimmunity following treatment with alemtuzumab
Jones JL, et al. ECTRIMS 2011, Amsterdam. P1009
Sensitivity NPV Specificity PPV
IL-21 alone 81 84 70 66
IL-7 alone 76 76 54 54
CCL21 alone 63 65 49 47
IL-21 or IL-7 98 97 41 55
IL-21 OR IL-7 OR CCL21
98 91 12 45
Given that pts may elect to receive treatment based
on results of this test – most weight given to
minimizing false negative results. Combining IL-21
and IL-7 into a single test offers improved test
accuracy over IL-21 alone. CCL21 did not improve
test accuracy
0
10
20
30
40
IL-7
Autoimmunity No autoimmunity
0
500
1000
1500
IL-2
1
1.0
Se
nsit
ivit
y
0.8
0.6
0.4
0.2
0.0 0.0 0.2 0.4 0.6 0.8 1.0
1.0
Se
nsit
ivit
y
0.8
0.6
0.4
0.2
0.0 0.0 0.2 0.4 0.6 0.8 1.0
1-Specificity
IL-21 and IL-7 levels in sera
of pts who did or did not
develop autoimmunity
Receiver operating
characteristic (ROC) curves
Anti-natalizumab Antibodies
Number of Patients at Risk
Placebo
Antibody Negative
Transiently Positive
Persistently Positive
315
568
20
37
296
550
19
32
283
538
18
26
264
526
16
25
248
506
16
24
240
487
16
22
229
480
15
22
216
470
14
19
208
460
14
16
200
449
14
15
Weeks
0.0
0.1
0.2
0.3
0.4
0.5
0 12 24 36 48 60 72 84 96 108 120
29%
Placebo
17%
Antibody Negative
17%
Transiently Antibody Positive
34%Persistently Antibody Positive
Cu
mu
lati
ve
Pro
po
rtio
n o
f P
ati
en
ts
wit
h S
us
tain
ed
Dis
ab
ilit
y
Pro
gre
ss
ion
(E
DS
S) *,†
*p ≤0.05 vs. antibody-negative patients†p=0.66 vs. placebo
Number of Patients at Risk
Placebo
Antibody Negative
Transiently Positive
Persistently Positive
315
568
20
37
296
550
19
32
283
538
18
26
264
526
16
25
248
506
16
24
240
487
16
22
229
480
15
22
216
470
14
19
208
460
14
16
200
449
14
15
Weeks
0.0
0.1
0.2
0.3
0.4
0.5
0 12 24 36 48 60 72 84 96 108 120
29%
Placebo
17%
Antibody Negative
17%
Transiently Antibody Positive
34%Persistently Antibody Positive
Cu
mu
lati
ve
Pro
po
rtio
n o
f P
ati
en
ts
wit
h S
us
tain
ed
Dis
ab
ilit
y
Pro
gre
ss
ion
(E
DS
S) *,†
*p ≤0.05 vs. antibody-negative patients†p=0.66 vs. placebo
0.73
0.220.16
0.48*
0.0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
Ad
jus
ted
An
nu
ali
ze
d R
ela
pse
Ra
te (
95
% C
I)
Placebo
(n=315)
Antibody Negative
(n=568)
Transiently
Antibody Positive
( n=20)
Persistently
Antibody Positive
(n=37)
*p=0.009 vs. antibody-negative patients
0.73
0.220.16
0.48*
0.0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
Ad
jus
ted
An
nu
ali
ze
d R
ela
pse
Ra
te (
95
% C
I)
Placebo
(n=315)
Antibody Negative
(n=568)
Transiently
Antibody Positive
( n=20)
Persistently
Antibody Positive
(n=37)
*p=0.009 vs. antibody-negative patients
Calabresi et al, Neurol 2007
Impact of anti-natalizumab antibodies on . . . . .
Annualized relapse rate Progressive disability
Natalizumab infusion reactions
• Acute hypersensitivity reactions are well-recognized
• Generalized urticaria, dizziness, fever, rash, rigors, pruritus, nausea, flushing, dyspnea, chest pain
• Onset generally during or within 1 hour of second infusion
• Incidence ~4%
• severe anaphylactic/anaphylactoid reactions <1%
• Most reactions are associated with anti-natalizumab antibodies
• Treatment:
• immediate and permanent cessation of natalizumab
• antihistamines
Rudick et al, NEJM 2006
Monitoring effect of therapeutic interventions
Reduced efficacy due to NAbs – systematic review
Farrell & Giovannoni, Multiple Sclerosis 2007; 13: 567-577.
Clinical importance of neutralising antibodies against interferon beta in patients with relapsing-remitting multiple sclerosis
Sorensen et al. Lancet 2003; 362: 1184–91.
Mean change in EDSS
Malluci et al. Neurology 2004.
Predictive markers for response to interferon therapy in patients with multiple sclerosis
Malucchi et al. Neurology 2008;70:1119–1127.
Jacob Elkins, James Sheridan, Lakshmi Amaravadi, Katherine Riester, Gilmore O’Neill
Neurology 2012;78(Suppl.): S31.004
Prognostic markers
Petzold, J Neurol Sci. 2005 Jun 15;233(1-2):183-98.
Petzold et al. J Neurol Neurosurg Psychiatry. 2005 Feb;76(2):206-11.
Spinal fluid neurofilament levels
Gunnarsson et al. Ann Neurol 2010; Epub.
CSF NFL
Can you help?
www.ms-res.org
ww
w.m
s-re
s.o
rg
N = 145
Gunnarsson et al. Ann Neurol 2010; Epub.
CSF NFL
Conclusion • Diagnostic/prognostic biomarkers
• Intrathecal OCBs
• IgG Index
• Pharmacovigilance
• Baseline screening
• Monoclonal gammaopathy (IFNbeta)
• Serology – VZV, JCV (immunosuppression)
• TB screening (immunosuppression)
• IL7:IL21, TPO (alemtuzumab)
• Monitoring
• FBC, LFTs, U&E, TFTs
• Monthly platelets and possibly urine (alemtuzmab)
• Serology – JCV (natalizumab)
• CD56-bright cells (daclizumab)
• NABs (IFNbeta and natalizumab)
• Potential surrogate treatment markers
• CSF neurofilament levels
• Potential future baseline response markers
• Type 1 interferon signature
• PBMC transcriptomic profiles
• Monoclonal IgM
• Anti-lipid antibodies
Acknowledgements • Giovannoni
• Sharmilee Gnanapavan
• David Baker
• Gareth Pryce
• Sarah Al-Izki
• Sam Jackson
• Katie Lidster
• Yuti Chernajovsky
• Alex Annenkov
• Anne Rigby
• Michelle Sclanders
• Larry Steinman
• Peggy Ho
• Charles ffrench-Constant
• Robin Franklin
• Siddharthan Chandran
• David Hampton
• Ian Duncan
• Sam Jackson
• Peter Calabresi
• Avi Nath
• Raj Kapoor
• John Zajicek
• Doug Brown
• UK MS Clinical Trial Network
• BioMS
• Co-investigators
• NABINMS
• Affirm study
• Care MS 1 & 2 studies
• Select trial