Long-term follow-up of patients with multiple sclerosis treated with a cost-effective protocol from a rural medical center in India: a retrospective case series
Sadanandavalli Retnaswami Chandra1, Nitin Ramanujam Chakravarthula2, Thomas Gregor Issac3, Mariamma Philip4
1 Department of Neurology, National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, Karnataka, India
2 Department of Neurochemistry, National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, Karnataka, India
3 Department of Psychiatry, National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, Karnataka, India
4 Department of Biostatistics, National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, Karnataka, India
|Date of Submission||18-Sep-2019|
|Date of Decision||20-Sep-2019|
|Date of Acceptance||15-Oct-2019|
|Date of Web Publication||12-Dec-2019|
Sadanandavalli Retnaswami Chandra
Department of Neurology, National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, Karnataka
Source of Support: None, Conflict of Interest: None
Background and objectives: Multiple sclerosis affects young adults resulting in dependency after 15 years of disease. Treatments are time-consuming, expensive and do not provide full protection. The purpose of this study is to assess the therapeutic effects of rational therapy on multiple sclerosis in patients from a tertiary centre, India.
Subjects and methods: This retrospective case series study included 23 patients treated with a very cost-effective protocol that was practiced for three decades in a government medical college setting in a population of 250 patients. All rational options were explained to the patients who were diagnosed with multiple sclerosis according to modified Mc Donald criteria. The patients who were willing to undergo the scheduled regime were followed up. Multiple sclerosis relapse, lesion load, and Expanded Disability Status scale (EDSS) scores were evaluated at 1 and 3 years and thereafter in a need based way. This study was approved by the Institutional Review Board, National Institute of Mental Health And Neurosciences (NIMHANS), India.
Results: The mean duration of illness of 23 patients with multiple sclerosis was 6.8 ± 5.23 years and the mean remission period was 4.09 ± 3.5 years. The mean EDSS score was 3.83 ± 0.78 at onset and it was 1.15 ± 0.5 after treatment. Thirteen (22%) patients had replaces during the above period of illness but were managed well with a pulse of 5 g methyl prednisolone.
Conclusion: The treatment protocol for multiple sclerosis designed for patients from an Indian rural medical center is cost-effective and has very good effects on the control of relapse and progression.
Keywords: atorvastatin; azathioprine; methotrexate; multiple sclerosis; oral penicillin; relapsing-remitting multiple sclerosis
|How to cite this article:|
Chandra SR, Chakravarthula NR, Issac TG, Philip M. Long-term follow-up of patients with multiple sclerosis treated with a cost-effective protocol from a rural medical center in India: a retrospective case series. Asia Pac J Clin Trials Nerv Syst Dis 2019;4:90-3
|How to cite this URL:|
Chandra SR, Chakravarthula NR, Issac TG, Philip M. Long-term follow-up of patients with multiple sclerosis treated with a cost-effective protocol from a rural medical center in India: a retrospective case series. Asia Pac J Clin Trials Nerv Syst Dis [serial online] 2019 [cited 2020 Jul 14];4:90-3. Available from: http://www.actnjournal.com/text.asp?2019/4/4/90/271802
| Introduction|| |
Multiple sclerosis (MS) is a recurrent demyelinating disease of white matter of the central nervous system, a medical curiosity in the 19th century and recognized as one of the common disease of young people which starts with episodic symptoms and signs and later becomes progressive (Murray, 2006; Schultz et al., 2019; Yu et al., 2019). Patients usually become dependent for activities of daily living (ADL) after 15 years of illness. Diagnosis can be made with 100% certainty only by histopathology. The McDonald Criteria was first established in 2001 and revised in 2010 (Polman et al., 2011). If two lesions are evident in first attack, it indicates dissemination in both time and space and qualifies for initiation of disease-modifying therapies. The Schumacher Criteria (1965) formulated clinical criteria. The Poser Criteria (1983) standardized the use of diagnostic tests such as evoked potentials and a spinal tap. The signs and symptoms depend on the location of the pathology and severity. MS affects the people aged between 15 and 60 years. Women have a twofold risk of developing MS compared with men. A family history further increases the risk. Virus infections are linked to MS such as Epstein-Barr virus (EBV). White people, particularly those of Northern European descent, are at highest risk of developing MS (Kingwell et al., 2013). People living in temperate climate and Asian, African or Native American descent have the lowest risk. It presents as relapsing-remitting type, primary progressive type, secondary progressive type and progressive relapsing type. There is a need to carefully exclude the differential diagnosis which includes vasculitis, secondary demyelination, infections and leukoencephalopathy associated with metabolic diseases. Treatment options are both disease modifying and symptom oriented. Most patients are forced to discontinue the standard recommendations due to unaffordability as duration of treatment is several years to lifetime (Goldberg et al., 2009). In this pilot study, we reported the efficacy of a cheap oral protocol we prescribed to patients based on level three recommendations in literature for azathioprine, methotrexate clubbed with atorvastatin for its role in neurogenic inflammation. Oral penicillin 800 mg a day was added based on our previous observation that even bacterial infections can precipitate a relapse by elevated antistreptolysin O titers found in our patients during relapse (Gray et al., 2004; Casetta et al., 2007; Noyes et al., 2011; Wang et al., 2011).
| Subjects and Methods|| |
This is a retrospective case series study. It was conducted at the National Institute of Mental Health and Neurosciences (NIMHANS) in Karnataka, India. Institutional review board approval was not obtained as these data were generated from a large sample of patients who opted for this regime based on literature evidence as they could not afford the usual drugs [Additional file 1] [Additional file 1]. Informed consent of the study procedure was obtained from all patients [Additional file 2] [Additional file 2].
The data was obtained from patients who were diagnosed with multiple sclerosis according to the modified Mc Donald’s criteria (Polman et al., 2011). After providing informed consent, the patients who were willing to participate in this study were given the new regimen as maintenance treatment for prevention of MS relapses with either azathioprine for patients who showed a relapsing trend or methotrexate for patients who had a progressive course (Goldberg et al., 2009) after detailed discussion with patients and their caregivers.
Sample size and follow-up
The need for prevention of factors like infections, need for sunlight exposure, stopping smoking, shifting to plant based diet, antioxidant rich foods, and trauma was explained to the included patients (Sibley et al, 1985; Hayes et al., 1997; Martinelli, 2000; Jafari et al., 2009). Though the treatment protocol had been practiced for three decades in more than 250 patients spreading over several medical colleges in Kerala state government, in this study, we only included the results of 23 consecutive patients who came for follow-up in the last 3 months in the NIMHANS from October 1, 2018 to December 31, 2018 and whose complete data was available as a pilot report on long-term effects.
Data collection and analysis
The included participants were followed up regularly over a period of 10 years from 2008 to 2018 at the NIMHANS. The illness was also confirmed radiologically by characterization of the lesion patterns and identification of lesion load and the location of lesions. Cerebrospinal fluid (CSF) was also collected to confirm the markers specific for MS. CSF anti-aquaporin-4 antibody assessment was also done to rule out cases of neuromyelitis optica. Clinical, radiological and serological data which were obtained were input into Excel sheet and analyzed by SPSS 21.0 software (IBM, Armonk, NY, USA).
| Results|| |
Twenty-three patients were identified during the period of data collection. The mean age of the study population was 34.74 ± 10.76 years (range, 17–55 years). The mean duration of illness was 6.8 ± 5.23 years and the mean duration of remission was 4.09 ± 3.5 years respectively. Vasculitis examination (to rule out secondary demyelination) results were negative in all patients. Among these 23 participants, 61% were females and 39% were males. 43.5% of the patients had associated pyramidal symptoms and none of the patients had extra pyramidal symptoms. Cerebellar symptoms and signs were present in 14 patients (61%), Lhermitte’s sign in 19 patients (83%). Cranial nerve involvement was present in 15 patients (65%). Cognitive decline was seen only in 2 patients (9%) and the remaining 21 patients (91%) had no features clinically suggestive of cognitive impairment. Cerebellar signs were present in 83% of included participants and cord signs appeared in > 90% of the population. CSF oligoclonal bands were positive in 20 patients (87%) and CSF neuromyelitis optica was negative in all patients except for one patient who had weakly positive titers of anti-neuromyelitis optica antibody in addition.
Magnetic resonance imaging was done for patients (56.5%) with cerebellar signal change and patients (91%) with spinal cord signal changes. About 25% (6) patients had parenchymal loss in brain imaging (black holes) prior to the initiation of treatment. 43.5% of the included patients did not suffer from any relapse during the treatment with the novel regimen, 26.7% of them having a single relapse which was managed with parenteral methylprednisolone 1 g daily for 5 days, and all of them recovered uneventfully. Multiple relapses (2 or more) were observed in only about 30% of the population. The provisional diagnosis of MS subtype made for the patients is depicted in the histogram below [Figure 1].
|Figure 1: Percentage of MS subtypes.|
Note: MS: Multiple sclerosis; PPMS: primary progressive multiple sclerosis; RRMS: relapsing-remitting multiple sclerosis; SPMS: secondary progressive multiple sclerosis.
Click here to view
There were 19 patients in the azathioprine group (82.6%) and 4 patients in the methotrexate group (17.4%). Expanded Disability Status scale (EDSS) was applied prior to and after treatment initiation and the difference in EDSS score between prior to and after treatment initiation was compared using Wilcoxon Sign Rank test as the sample size was relatively small. There was significant difference in disability rating between prior to and after treatment initiation (P < 0.001). The mean EDSS score was 3.83 ± 0.78 and 1.15 ± 0.5 prior to and after treatment initiation, respectively. This suggests an improvement from moderate disability in one functional system to no disability with minimal signs in one functional system. The patients treated with azathioprine regimen showed significant improvement compared with that in patients receiving methotrexate regimen (P < 0.001). There was also significant difference in the disability scores measured by EDSS between patients who had no relapses and those who had relapses (P = 0.005). Patients having no relapses showed a better outcome with lesser disability compared with those having relapses. About 45% of patients had no relapses after receiving the new regimen during the follow up period studied. The magnetic resonance imaging evidence of lesion load reduction was seen in all patients at the end of 1 year and 3 years. But complete resolution of lesions was not seen even in patients who were clinically in good remission (see [Figure 2] for typical cases). None of the patients in this group had bone marrow suppression or tumors.
|Figure 2: Magnetic resonance images of a 25-year-old male patient (A) and a 29-year-old female patient (B) at onset of multiple sclerosis (A1, B1) and 3 years after treatment (A2, B2).|
Note: (A1) Axial flair images with multiple periventricular white matter changes and spine showing hyperintensity in cervical region with bulkiness. (A2) Images show very minimal lesions and atrophic spinal cord. (B1) Both sagittal and axial images show extensive T2 hyperintense lesions. (B2) Images show considerable reduction in lesion load.
Click here to view
| Discussion|| |
In this pilot report, we analyzed the data of 23 patients who came for follow up with the mean illness duration of 6.8 ± 5.23 years and the mean remission duration of 4.09 ± 3.5 years respectively. There was significant reduction in EDSS scores. Statistical data rejected the null hypothesis with a significance level of 0.5. The cost of the regime is approximately 5000 INR (Indian Rupees) per year. Azathioprine used at 1 mg/kg had no side effects in any of the included patients. Statins interfere with production of several proinflammatory mediators including inducible nitric oxide synthase, tumor necrosis factor alpha (TNFα), and inducible major histocompatibility complex (interferon gamma) (Weber et al., 2005). MHC class II genes are concerned with susceptibility to MS being at the core of the destructive cascade (Chow, 2009). Statins bind to lymphocyte functional antigen (LFA-1), inhibit mevolonate pathway, and exhibit neuroprotective effects in the long run (Stalker et al., 2001; Schramm et al., 2007; van der Most et al., 2009). Azathioprine inhibits cell proliferation by inhibiting purine synthesis (Yudkin et al., 1991). It has been tried alone or in combination with other therapies with variable results. Methotrexate inhibiting dihydrofolate reductase in rapidly multiplying cells and the underlying benefits were reported in studies in patients with progressive multiple sclerosis (Goodkin et al., 1996; Billups et al., 2000). Cost is an important factor in patients receiving long term treatment and it has to be taken into consideration in countries where there is no uniform insurance coverage and patients have to spend for treatment when their role as active breadwinners is hampered by disease. This is all the more relevant when the popular regimes are also able to give only partial protection against relapses and progression (Leppert et al., 1996).
There are limitations in this study. Even though a large number of patients are successfully treated in this regime, this pilot report included only patients who came for follow up in the last 3 months of 2018 due to practical problems as this is a non-funded study and has no personnel to support the evaluation. The patients who were on other regimes were not used as controls.
Taken together, this pilot report of patients who were randomly recruited for evaluation reveals the combination of azathioprine 1 mg/kg, atorvastatin 10 mg/day, and oral penicillin 800 mg/day used in patients with relapsing-remitting multiple sclerosis significantly reduced clinical disability at a very cost-effective way that is most suited for resource limited nations. Methotrexate 7.5 mg/week was used in place of azathioprine in patients with progressive course with good results with reference to relapses, disability, and safety. Radiological reduction of lesion load at 1-year and 3-year follow-up was partial. There were no serious side effects in any patient. The regime is relatively safe during pregnancy as most patients are young females. This regime should be tried in low income patients with confidence as no regime currently available either completely prevents relapses or lesion load in imaging.
Additional file 1: IRB Approval.
Additional file 2: Model consent form.
We express our gratitude to the patient and families for the faith they kept in us.
Study conception: SRC, MP. Study design: NRC. Definition of intellectual content, clinical and experimental studies, and guarantor: SRC. Literature retrieval: SRC, TGI. Data acquisition: NRC, TGI, MP. Data analysis, statistical analysis, manuscript preparation, editing, and review: TGI, MP. All authors approved the final manuscript for publication.
Conflicts of interest
The authors have no conflicts of interest to declare.
Institutional review board statement
Institutional review board approval was not obtained as these data were generated from a large sample of patients who opted for this regime based on literature evidence as they could not afford the usual drugs. This study was performed according to the Declaration of Helsinki, and informed consent of the study procedure was obtained from all participants.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the forms, the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity.
This study followed the STrengthening the Reporting of OBservational studies in Epidemiology (STROBE) statement.
The statistical methods of this study were reviewed by the biostatistician of National Institute of Mental Health And Neurosciences (NIMHANS), India.
Copyright license agreement
The Copyright License Agreement has been signed by all authors before publication.
Data sharing statement
Individual participant data that underlie the results reported in this article, after deidentification (text, and tables), will be available upon request. Data will be available immediately following publication, no end date for anyone who wishes to access the data. In order to gain access, data requestors will need to sign a data access agreement. Proposals should be directed to firstname.lastname@example.org.
Checked twice by iThenticate.
Externally peer reviewed.
Open access statement
This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.
P-Reviewers: Li D, Bai YS; C-Editor: Zhao M; S-Editor: Li CH; L-Editor: Song LP; T-Editor: Jia Y
| References|| |
Billups SJ, Malone DC, Carter BL (2000) The relationship between drug therapy noncompliance and patient characteristics, health-related quality of life, and health care costs. Pharmacotherapy 20:941-949.
Casetta I, Iuliano G, Filippini G (2007) Azathioprine for multiple sclerosis. Cochrane Database Syst Rev:CD003982.
Chow SC (2009) Immunomodulation by statins: mechanisms and potential impact on autoimmune diseases. Arch Immunol Ther Exp (Warsz) 57:243-251.
Goldberg L, Edwards NC, Fincher C, Doan QV, Al-Sabbagh A, Meletiche DM (2009) Comparing the cost-effectiveness of disease-modifying drugs for the first-line treatment of relapsing-remitting multiple sclerosis. J Manag Care Pharm 15:543-555.
Goodkin DE, Rudick RA, Medendorp SV, Daughtry MM, Van Dyke C (1996) Low-dose oral methotrexate in chronic progressive multiple sclerosis: analyses of serial MRIs. Neurology 47:1153-1157.
Gray O, McDonnell GV, Forbes RB (2004) Methotrexate for multiple sclerosis. Cochrane Database Syst Rev:CD003208.
Hayes CE, Cantorna MT, DeLuca HF (1997) Vitamin D and multiple sclerosis. Proceedings of the Society for Exp Biol Med 216:21-27.
Jafari N, Hoppenbrouwers IA, Hop WC, Breteler MM, Hintzen RQ (2009) Cigarette smoking and risk of MS in multiplex families. Mult Scler 15:1363-1367.
Kingwell E, Marriott JJ, Jetté N, Pringsheim T, Makhani N, Morrow SA, Fisk JD, Evans C, Béland SG, Kulaga S, Dykeman J, Wolfson C, Koch MW, Marrie RA (2013) Incidence and prevalence of multiple sclerosis in Europe: a systematic review. BMC Neurol 13:128.
Leppert D, Waubant E, Bürk MR, Oksenberg JR, Hauser SL (1996) Interferon beta-1b inhibits gelatinase secretion and in vitro migration of human T cells: a possible mechanism for treatment efficacy in multiple sclerosis. Ann Neurol 40:846-852.
Martinelli V (2000) Trauma, stress and multiple sclerosis. Neurol Sci 21:S849-852.
Murray TJ (2006) Diagnosis and treatment of multiple sclerosis. BMJ 332:525-527.
Noyes K, Bajorska A, Chappel A, Schwid SR, Mehta LR, Weinstock-Guttman B, Holloway RG, Dick AW (2011) Cost-effectiveness of disease-modifying therapy for multiple sclerosis: a population-based study. Neurology 77:355-363.
Polman CH, Reingold SC, Banwell B, Clanet M, Cohen JA, Filippi M, Fujihara K, Havrdova E, Hutchinson M, Kappos L, Lublin FD (2011) Diagnostic criteria for multiple sclerosis: 2010 revisions to the McDonald criteria. Ann Neurol 69:292-302.
Schramm R, Menger MD, Harder Y, Schmits R, Adam O, Weitz-Schmidt G, Schäfers HJ (2007) Statins inhibit lymphocyte homing to peripheral lymph nodes. Immunology 120:315-324.
Schultz TJ, Thomas A, Georgiou P, Cusack L, Juaton M, Simon L, Naidoo K, Webb K, Karnon J, Ravindran J (2019) Developing a model of care for home infusions of natalizumab for people with multiple sclerosis. J Infus Nurs 42:289-296.
Sibley W, Bamford C, Clark K (1985) Clinical viral infections and multiple sclerosis. Lancet 1:1313-1315.
Stalker TJ, Lefer AM, Scalia R (2001) A new HMG-CoA reductase inhibitor, rosuvastatin, exerts anti-inflammatory effects on the microvascular endothelium: the role of mevalonic acid. Br J Pharmacol 133:406-412.
van der Most PJ, Dolga AM, Nijholt IM, Luiten PG, Eisel UL (2009) Statins: mechanisms of neuroprotection. Prog Neurobiol 88:64-75.
Wang J, Xiao Y, Luo M, Luo H (2011) Statins for multiple sclerosis. Cochrane Database Syst Rev:CD008386.
Weber MS, Prod’homme T, Steinman L, Zamvil SS (2005) Drug Insight: using statins to treat neuroinflammatory disease. Nat Rev Neurol 1:106.
Yu F, Fan Q, Tian Q, Ngamsombat C, Machado N, Bireley JD, Russo AW, Nummenmaa A, Witzel T, Wald LL, Klawiter EC, Huang SY (2019) Imaging G-ratio in multiple sclerosis using high-gradient diffusion MRI and macromolecular tissue volume. AJNR Am J Neuroradiol doi: 10.3174/ajnr.A6283.
Yudkin PL, Ellison GW, Ghezzi A, Goodkin DE, Hughes RA, McPherson K, Mertin J, Milanese C (1991) Overview of azathioprine treatment in multiple sclerosis. Lancet 338:1051-1055.
[Figure 1], [Figure 2]