A moan…Doing trials to pat yourselves on the back for a paper and a job well-done is not what it’s about… Changing clinical practise is what it’s all about

A

A couple of years ago Dr Raj Kappoor and ProfG did a trial in optic neuritis and tested a sodium channel blocker to see if it could save nerves in the eye after optic neuritis. This was based on studies that MD1, 2, 3 & 4 had done in the beasties.

The trial worked and it saved loss of nerves by about 30%, but then what?….Yep Nothing.

I said to the neuros..”You have done a trial and it worked. Why not do a follow up?. Why is there no change in clinical practise?”. Surely anyone in relapse or sub-clinical relapse (new lesion) should at least get or be offered, sodium channel blockers to protect against the “inflammatory penumbra” (damage associated with the generation of an inflammatory lesions) that occurs when lesions occur.

I remember when I asked Dr Kappor, why was there no follow-on study? The answer was because there was no clinical effect, people were not loosing sight, so why do it?…..I thought duh.

A lost nerve is a lost nerve. You only get clinical problems when you have lost sufficient nerves to exhaust your reserve….Diabetes occurs when you have lost 80% of your pancreatic beta cells, Parkinsons disease occurs when you have lost lots of dopaminergic cells . How can you happily burn your reserve away. How can you happily allow other people to burn their reserve away…

However the softly, softly brigade do it, in my opinion, with the use of CRAB drugs that do not get disease under effective control for most people.

Now OK, I am not treating people and maybe the neuros are considering the balance as sodium channel blockers are not without side effects, but Dr Kapoor and to some extent profG, by their inactivity in trying to change clinical practise have contributed to people losing their sight reserve and probably brain reserve. Now profG may argue he has done something, but change clinical practise? Has that occurred?.

ProfKappoor did this studyafter we revived the idea after prof Smith and Kapoor messed up by doing a trial with outcome that was no good and chose a drug and dose that caused side effects and stopped people taking their treatment. NDG saved the day otherwise this would be a dead duck.

I know getting funding to do the same study is very difficult. But surely there is no point in undertaking trials unless there is a plan to do something with the information if it is positive. I do not think academics think enough about this.

How long is it since MS-STAT before MS-STAT2 ? No forward planning from the PIs and funders. Wasting so much time. As an academic we are judged on impact but as a scientist we are powerless to make things happen. If ideas stall because of ineffective trial design or clinical activity. If you see improvement in walking speed would that convince you something is happening…two studies .

Normal Visual Recovery after Optic Neuritis Despite Significant Loss of Retinal Ganglion Cells in Patients with Multiple Sclerosis.Sherif M, Bergin C, Borruat FX. Klin Monbl Augenheilkd. 2019 Apr;236(4):425-428

BACKGROUND:Optic neuritis (ON) is a frequent manifestation of demyelinating attack in multiple sclerosis (MS). Initial visual loss can vary from minimal to complete. Visual improvement occurs in about 95% of patients, some of them recovering to normal [visual acuity (VA), color vision, visual field (VF)]. We analyzed retinal ganglion cell layer (RGCL) thickness in MS patients who recovered their normal vision after ON to determine whether a relative preservation of RGCL existed in these patients.

MATERIALS AND METHODS: We conducted a retrospective study of all patients with MS and ON examined by one of us (F. X. B.) between 2013 and 2018. Inclusion criteria were strictly unilateral ON, full recovery of vision, computerized visual field, and OCT examinations. Full recovery of vision was defined as VA ≥ 10/10, Ishihara ≥ 11/13, and VF mean defect (MD) ≤ 2.6 dB. Evaluation of RGCL was obtained with spectral domain optical coherence tomography (SD-OCT). The normal fellow eye of all patients served as the control group. Relative thinning of RGCL, expressed as percentage, was calculated by comparing results from the affected eye to the fellow eye of the same patient.

RESULTS:Twenty-one patients (21 affected eyes – Group 1, 21 normal fellow eyes – Group 2) satisfying the inclusion criteria were retrieved from our database. All patients exhibited the relapsing-remitting form of MS. There were 16 women and 5 men. Mean age was 39.3 years old. There were no statistically significant differences between Group 1 and Group 2 for either VA (p = 0.3934) or Ishihara (p = 0.140), but a significant difference was found for VF MD (p = 0.0405). A markedly significant difference for RGCL thickness (p = 0.0001) was found, without any correlation with the degree of visual recovery. A subgroup of patients (n = 14) was examined at the time of initial visual loss. We correlated their results of visual function to the final RGCL thickness, and a correlation was found between either the initial VA loss or the initial VF loss and the final loss of RGCL (R2 = 0.4075 and R2 = 0.00739, respectively).

CONCLUSIONS: In our study, all patients with ON lost a significant amount of RGCL despite a full recovery of vision, as defined by our criteria. The percentage of RGCL loss varied from 5 - 27% and could not be correlated with any final visual indices. However, a correlation was found with the degree of initial visual loss. Despite sometimes marked RGCL loss after ON, patients with MS can recover normal visual function, according to standard clinical tests.

So with one attack of optic neuritis you have lost 5-27% of your visual reserve Wouldn’t you want to save it?

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MouseDoctor

10 comments

  • Mouse – nice rant (I assume you didn’t get an Easter Egg from Mrs Mouse or Prof G). I’ve lost track of all the early trials with “promising agents” that have delivered zilch. Various agents for neuroprotection, minocycline (and other antibiotics), estriol (lady hormone), anti-viral (remember Aus Prof G and all the positive presentations before the actual results were known), cannaboids…. I’ve worked out for that these trials were never intended to deliver treatments that would be available at your local Boots (or other pharmacies). They provide academics with the ability to produce lots of papers and turn up to International conferences. I never contribute to the MS Society research pot as I can’t think of one piece of research that has actually changed the lives of MSers ie no therapy has been brought to market. I think MS research is in the doldrums and following a similar pattern = treatment is approved; lots of research papers showing the benefits of the treatment (years 1-5); bits of research showing side effects (some serious); treatment gets pulled; more research analysing why side effects occurred… (this happened for Tysabri, Dacluzimab, Lemtrada). It’s a gravy train for MS researchers. I wonder why research into cancers is so different ie they really get to understand the mechanisms of the cancer then trial treatments to target the mechanisms (often with very good results). MS research follows this pattern: we don’t understand the disease (cause, mechanisms, why more woman are affected…) so let’s just try a therapy (often created for another disease). It doesn’t fill me with confidence.

    Enough of my ranting. Enjoy Easter Sunday.

    • I didn’t get any easter eggs….MrsMouse saved me some of hers but it was plain chocolate and i hate that so no extra calories for me.

  • Yes, I would want to save it! I went almost blind from Optic Neuritis, and Evoked Potential tests showed my eyes are permanently damaged. I would take mediation that may prevent further loss.

    As a patient, getting medications is an ongoing struggle. I’m on Modafinil, but it’s a hard drug to get and I worry they will take if off me. It took me many years to get Melatonin. I can’t get better pain meds than Tramadol. Tasimelteon has been licensed for my sleep disorder, but I cant get a doctor to prescribe it. I’m on Plegridy but haven’t been able to access Lemtrada. Ocrevus, or especially HSCT. Not to mention all the many years the NHS wouldn’t even let me see a neurologist.

    Medication existing it not the same as an actual patient being able to access it. I always think that, in my lifetime, a cure for MS that I can access won’t exist. Because it existing, and someone like me being able to get my hands on it, are totally different things.

    It’s about money, more than anything else, I think, in the end. And judgements about whose life matters, and what parts of their life matters. How old are they? What earning potential do they have? How much will it cost? How much fuss will they make if they don’t get it? How disabled are they? Will anyone care?

  • Which sodium channel blocker was used?

    Any news yet on PROXIMUS? (Protective Role of OXcarb in MS, ie is oxcarbazepine 300mg twice daily neuroprotective?).

    Sodium channel blockers easily available from GP, eg pwMS can ask to try for pain relief

    Happy Easter to all 🙂

    • In the Potic neuritis trial phenytoin was used…the worst neuroproptective in the hands of the MDs and Prof Smith, but it was used because you could load the dose quickly, the others autoinduce their own desrtuction so you have to increase the dose.

      PROXIMUS will be presented at ECTRIMS and its surprises with an n = 15 per group, should be easy to reproduce. One thing is clear.. You guys are not representative as few people were willing to do the lumbar punctures, but do you need them…probably not.

  • Thank you MD for the most refreshing post that I have read on this blog since its inception.

    It is too bad that someone with common sense, like you or MD2, was not overseeing funding or steering committees or MS Societies or approval boards instead of some of the main players these days influenced by money, power and Pharma.

    As a former researcher and physician, I am appalled at the lack of progress and innovation in MS research. History will not be kind to those researchers and neurologists whose main aim is for self-propagation and self-indulgence instead of the what they signed up for which is helping others.

  • Will this be a wake-up call? Why do the results not lead to further investigation?
    We need people like you to ask these awkward questions but I think your name might be deleted from a few Christmas card lists.

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