546786
research-article2014
MSJ0010.1177/1352458514546786Multiple Sclerosis JournalL Grau-López, A Teniente-Serra
MULTIPLE SCLEROSIS MSJ JOURNAL
Short Report
Similar biological effect of high-dose oral versus intravenous methylprednisolone in multiple sclerosis relapses
Multiple Sclerosis Journal 2015, Vol. 21(5) 646–650 DOI: 10.1177/ 1352458514546786 © The Author(s), 2014. Reprints and permissions: http://www.sagepub.co.uk/ journalsPermissions.nav
L Grau-López, A Teniente-Serra, M Tintoré, A Rovira, L Ramió-Torrenta, L Brieva, A Saiz, A Cano, O Carmona, JV Hervás, EM Martínez-Cáceres and C Ramo-Tello
Abstract Our aim was to investigate differences in immune mechanisms in multiple sclerosis (MS) relapse, after high-dose oral methylprednisolone (oMP) or intravenous methylprednisolone (ivMP). We measured serum cytokines (IL-2, IL-4, IL-6, IL-10, IL-17, TNF-α and IFN-γ) in 39 of 49 MS patients with moderate-severe relapse, whom were treated with ivMP or oMP in a placebo-controlled, non-inferiority clinical trial. We assessed these cytokine levels at baseline and at 1 and 4 weeks post-treatment. The cytokine levels between oMP and ivMP were similar at any time. Proinflammatory cytokines (IL-6 and IFN-γ) were significantly decreased in both groups at week 1 (p = 0.05 / p = 0.03) and at week 4 (p = 0.04 / p = 0.05). This study provides further confirmatory evidence that oMP is not inferior to ivMP. Trial registration: clinicaltrials.gov identifier: NCT00753792
Keywords: Clinical trial, cytokines, dosage forms, methylprednisolone, multiple sclerosis, relapses Date received: 7 April 2014; accepted: 9 July 2014
Introduction Relapsing–remitting multiple sclerosis (RRMS) is a chronic inflammatory, demyelinating disease of the central nervous system (CNS) of unknown etiology. It is characterized by periods of neurological dysfunction (relapses), followed by periods of clinical remission. During relapses in multiple sclerosis (MS) there is lymphocyte activation, extravasation and infiltration into the CNS, together with activation of immunocompetent glial cells that leads to myelin destruction. The proinflammatory Type 1 helper T (Th1) cytokines tumor necrosis factor-α (TNF-α), interferon-γ (IFN-γ) and interleukin-2 (IL-2) are related to inflammation and tissue damage. The Th2 cytokines IL-10 and IL-4 contribute to suppression of disease activity.1,2 Administration of methylprednisolone (MP) shortens the recovery period following a MS relapse,3 through the inhibition of immune function.4,5 MP decreases proinflammatory cytokines (the chemokine CCL2, TNF-α and IL-6) in peripheral blood and cerebrospinal fluid (CSF) of
patients with MS relapse.6,7 An immediate (at 5 days), but not long-term (1 month), increase in anti-inflammatory cytokines (IL-10) is also reported.2,4 In keeping with the hypothesis investigated by other authors, oral MP (oMP) is not clinically nor radiologically inferior to intravenous MP (ivMP), and in that it is equally well-tolerated and safe,8–10 we conducted a Phase-IV, multicenter, double-blind, randomized, non-inferiority clinical trial, to compare bioequivalent high-dose oMP versus ivMP to treat MS relapses, and we provided confirmatory evidence that bioequivalent high-dose oMP is not clinically nor radiologically inferior to ivMP, and that it is equally well tolerated and safe.11 The objective of the current study was to investigate possible differences in immune mechanisms upon diagnosis of a MS relapse (baseline) and at both 1 and 4 weeks after initiation of treatment with either oMP (1250 mg/24 h) or ivMP (1000 mg/24 h) for a period of 3 days.
Correspondence to: Laia Grau-López Department of Neurosciences, Hospital Germans Trias i Pujol, C/ Canyet s/n 08916 Badalona, Spain. [email protected] L Grau-López A Teniente-Serra JV Hervás EM Martínez-Cáceres C Ramo-Tello Hospital Germans Trias i Pujol, Badalona, Spain/ Universitat Autònoma de Barcelona, Spain M Tintoré A Rovira Hospital Vall D’ Hebron, Barcelona, Spain L Brieva Hospital Arnau de Vilanova, Lleida, Spain L Ramió-Torrenta Hospital Dr Josep Trueta, Girona, Spain A Saiz Hospital Clinic, Barcelona, Spain A Cano Hospital de Mataró, Mataró, Spain O Carmona Hospital de Figueres, Figueres, Spain
646 http://msj.sagepub.com
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L Grau-López, A Teniente-Serra et al. Methods
p value of < 0.05 was considered to be statistically significant.
Patients We analyzed serum cytokines in 39 of 49 MS patients whom had agreed to participate in the immunological analysis from a Phase-IV, multicenter, double-blind, randomized clinical trial.11 There were no differences in clinical and radiological variables between patients who had accepted and patients who had denied to participate in the immunological analysis. The study included adults whom met the 2005 McDonald criteria for RRMS and had experienced a relapse. The inclusion criteria were: (a) An age of 18 to 59 years; (b) An Expanded Disability Status Scale (EDSS) score of 0 to 5.0, prior to relapse; (c) Recent onset (< 15 days) of relapse; and (d) One month of clinical stability, prior to relapse. The exclusion criteria were: isolated clinical syndrome, progressive MS, use of steroids during the previous 3 months and use of natalizumab or immunosuppressive therapy at any time (concomitant treatment with interferon and glatiramer acetate was allowed). The trial protocol was approved by the ethics committees of all the participating centers and the trial was appropriately registered (ClinicalTrials.gov; no. NCT00753792). We obtained written informed consent before randomization, in all cases. We collected 10 ml blood samples at baseline, and at weeks 1 and 4, after treatment with oMP (n = 20) or ivMP (n = 19).
Results There were no differences in cytokine levels after treatment with oMP versus ivMP No significant differences were observed in cytokine levels between patients treated with oMP versus ivMP at baseline, week 1 and week 4 (Table 1). Treatment with either ivMP or oMP induced a decrease in proinflammatory cytokines Proinflammatory cytokines (IL-6 and IFN-γ) were significantly reduced at week 1 and week 4 post-treatment initiation in all patients (p = 0.05 and p = 0.05), as seen in Figure 1(a) and Figure 1(b); and in patients treated with ivMP (n = 19; p = 0.05 and p = 0.03) and oMP (n = 20; p = 0.04 and p = 0.05), respectively (Figure 1(c) and Figure 1(d)). Serum levels of IL-2, IL-17 and TNF-α were below the detection limit in most patients; but in those cases in which IL-17 (n = 6) and TNF-α (n = 8) were detected, a decrease was found with respect to baseline (Figure 1(e) and Figure 1(f)).Levels of anti-inflammatory cytokines (IL-10 and IL-4) were not significantly altered by treatment (n = 39; p = 0.26 and p = 0.12) (Figure 1(g) and Figure 1(h)).
Analysis of cytokine production We obtained the serum from blood after 10 minutes of centrifugation at 1800 rpm, and then froze the sera at − 80ºC, until our analysis for seven cytokines (IL-2, IL-4, IL-6, IL-10, IL-17, TNF-α and IFN-γ). Cytokine levels were determined at baseline and at weeks 1 and 4. Cytokine levels were quantified in undiluted sera, using a cytokine bead array kit (BD Biosciences), and then analyzed by flow cytometry (FACSCanto II, BD Biosciences). The detection limits were set: 1.07 pg/ ml for IL-2, 0.85 pg/ml for IL-4, 0.77 pg/ml for IL-6, 0.87 pg/ml for IL-10, 0.74 pg/ml for IL-17, 0.74 pg/ ml for TNF-α and 0.67 pg/ml for IFN-γ.
Discussion This study provides immunological evidence that bioequivalent high-dose oMP is not different to ivMP in the treatment of MS relapses. Previously, we demonstrated that oMP was not inferior to ivMP, in terms of reducing the patients’ EDSS scores and magnetic resonance imaging (MRI) lesions after 4 weeks, in patients with MS relapses, and we also showed that it was equally well tolerated and safe.11 Here we have shown, in a subset of patients from the trial, that there were no significant differences in serum cytokine levels between both dosage forms, before and 1 and 4 weeks after treatment, providing evidence that oMP is not mechanistically different to ivMP in the treatment of MS relapses. To our knowledge, this is the first study comparing cytokine levels after oMP and ivMP treatment in MS patients.
Statistical analysis We compared the cytokine levels between the two treatments groups, using unpaired Student’s t test. A
In our study, basal levels of anti-inflammatory cytokines (IL-4 and IL-10) were not modified after treatment with oMP or ivMP, at 1 week nor at 4 weeks. Despite the effect of MP on cytokines has been widely
http://msj.sagepub.com 647
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Multiple Sclerosis Journal 21(5) Table 1. Cytokine levels (pg/ml) in both treatment groups.
ivMTP (n = 19)
oMTP (n = 20)
p
IL-2a IL-4 IL-6 IL-10 TNFαa IFNγ IL-17a Week 1 (t = 1) IL-4 IL-6 IL-10 IFNγ
15.5 (SD 14.4) 2.2 (SD 0.8) 2.75 (SD 1.34) 2.45 (SD 0.62) 2.38 (SD 1) 5.37 (SD 11.45) 82.9 (SD 101.7)
14.3 (SD 18.6) 1.9 (SD 0.7) 3.16 (SD 2.8) 1.63 (SD 0.43) 2.4 (SD 0.39) 6.86 (SD 17) 78.9 (SD 115)
0.44 0.73 0.11 0.46 0.44 0.55 0.92
2.31 (SD 0.75) 2.3 (SD 0.76) 2.08 (SD 0.2) 2.12 (SD 0.67)
2.17 (SD 0.46) 1.87 (SD 0.5) 1.21 (SD 0.46) 1.8 (SD 0.51)
0.08 0.13 0.6 0.43
ivMP (n = 19)
oMP (n = 20)
p
Week 4 (t = 2) IL-4 IL-6 IL-10 IFNγ
2.22 (SD 0.58) 1.97 (SD 0.43) 1.49 (SD 0.15) 2.16 (SD 1.22)
1.97 (SD 0.4) 1.74 (SD 1.81) 1.38 (SD 0.77) 1.74 (SD 0.48)
0.12 0.08 0.26 0.07
Basal (t = 0)
aTNFα, IL17 and IL2 were below detection levels of the technique used, at Week 1 and Week 4, in n = 31, 33 and 39 patients, respectively. IFN: interferon; IL: interleukin; ivMP: intravenous methylprednisolone; oMP: oral methylprednisolone; TNF: tumor necrosis factor.
studied, only a few studies demonstrate a clear effect on anti-inflammatory cytokines2,12; however, the effect of MP treatment on pro-inflammatory cytokines in MS relapses has been demonstrated more extensively.6,13 We also observed a decrease in pro-inflammatory cytokine production (IL-6 and IFN-γ) at both 1 and 4 weeks post-treatment. Decreases in proinflammatory cytokines are easier to detect than antiinflammatory cytokines, following treatment with steroids, because patients with MS typically experience a clear, detectable increase in pro-inflammatory, but not anti-inflammatory, cytokines during relapse.6 IFN-γ has a great impact on the regulation of the immune response: It stimulates the differentiation of Th1 cells, inhibits the differentiation of Th2 cells and activates cytotoxic T cells. Furthermore, IFN-γ influences antibody production and stimulates macrophages to produce TNF-α, IL-1, IL-6 and IL-8. We have demonstrated that MP treatment of relapses induces immediate post-treatment and short-term decrease in IFN-γ that could partly account for the clinical and radiological improvements observed in MS patients.14
All of the patients in our series were treated with steroids. A comparison of cytokine levels between treated and untreated patients would be useful for determining cytokine changes over time, but this is generally not feasible, as steroid treatment needs to be implemented in most cases of moderate or severe relapse. In conclusion, we observed no differences in cytokine levels between patients treated with oMP or ivMP, providing further support showing that the two modes of administration are equivalent. These findings support the use of oMP to treat MS relapses, to spare patients from more invasive, less convenient and more costly medical procedures. Conflict of interest None declared. Funding This work was supported in part by the Ministry of Health of Spain (grant no. EC07/90278) and by Biogen Idec.
648 http://msj.sagepub.com
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L Grau-López, A Teniente-Serra et al.
Figure 1. Figure 1(a) IL-6 levels decreased at week 1 (p = 0.05) and week 4 (p = 0.05) in all patients (n = 39); (b) IFN-γ levels decreased at week 1 (p = 0.05) and week 4 (p = 0.02) in all patients (n = 39); (c) IL-6 levels decreased at week 1 (p = 0.05) and week 4 (p = 0.04) in patients treated with ivMP (n = 19) and oMP (n = 20); (d) IFN-γ levels decreased at week 1 (p = 0.03) and week 4 (p = 0.05) in patients treated with ivMP (n = 19) and oMP (n = 20); (e) IL-17 levels decreased at week 1 and week 4 in patients treated with ivMP (n = 3) and oMP (n = 3); (f) TNF-α decreased at week 1 and week 4 in patients treated either ivMP (n = 4) or oMP (n = 4); (g) there were no significant changes in IL-10 levels (p = 0.26) nor (h) IL-4 levels (p = 0.12) after treatment with either ivMP or oMP (n = 39). http://msj.sagepub.com 649
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Multiple Sclerosis Journal 21(5)
References 1. Cannella B and Raine CS. The adhesion molecule and cytokine profile of multiple sclerosis lesions. Ann Neurol 1995; 37: 424–435. 2. Gayo A, Mozo L, Suarez A, et al. Glucocorticoids increase IL-10 expression in multiple sclerosis patients with acute relapse. J Neuroimmunol 1998; 85: 122–130. 3. Pozzilli C, Marinelli F, Romano S, et al. Corticosteroid treatment. J Neurol Sci 2004; 223: 47–51. 4. Rentzos M, Nikolau C, Rombos A, et al. Effect of treatment with methylprednisolone on the serum levels of IL-12, IL-10 and CCL2 chemokine in patients with multiple sclerosis in relapse. Clin Neurol Neurosurg 2008; 110: 992–996. 5. Martinez-Cáceres E, Barrau MA, Brieva L, et al. Treatment with methylprednisolone in relapses of multiple sclerosis patients: Immunological evidence of immediate and short-term but not long-lasting effects. Clin Exp Immunol 2002; 127: 165–171. 6. Baraczka K, Nekam K, Pozsonyi T, et al. Investigation of cytokine (tumor necrosis factoralpha, interleukin-6, interleukin-10) concentrations in the cerebrospinal fluid of female patients with multiple sclerosis and systemic lupus erythematosus. Eur J Neurol 2004; 11: 37–42. Visit SAGE journals online http://msj.sagepub.com
SAGE journals
7. Matsushita T, Tateishi T, Isobe N, et al. Characteristic cerebrospinal fluid cytokine/chemokine profiles in neuromyelitis optica, relapsing remitting or primary
progressive multiple sclerosis. PLoS One 2013; 8: e61835. 8. Alam SM, Kyriakides T, Lawden M, et al. Methylprednisolone in multiple sclerosis: A comparison of oral with intravenous therapy at equivalent high dose. J Neurol Neurosurg Psychiatry 1993; 56: 1219–1220. 9. Sharrack B, Hughes RA, Morris RW, et al. The effect of oral and intravenous methylprednisolone treatment on subsequent relapse rate in multiple sclerosis. J Neurol Sci 2000; 173: 73–77. 10. Martinelli V, Rocca MA, Annovazzi P, et al. A short-term randomized MRI study of high-dose oral vs intravenous methylprednisolone in MS. Neurology 2009; 73: 1842–1848. 11. Ramo-Tello C, Grau-López L, Tintoré M, et al. A randomized clinical trial of oral versus intravenous methylprednisolone for relapse of MS. Mult Scler 2014; 20: 717–725 12. So EY, Kim SH, Park HH, et al. Corticosteroid inhibits IL-4 signaling through down-regulation of IL4 receptor and STAT6 activity. FEBS Lett 2002; 518: 53–59. 13. Dufour A, Salmaggi A, La Mantia L, et al. Highdose methylprednisolone treatment-induced changes in immunological parameters in progressive MS patients. Int J Neurosci 1994; 75: 119–128. 14. Petermann F and Khorn T. Cytokines and effector T-cell subsets causing autoimmune CNS disease. FEBS Lett 2011; 585: 3747–3757.
650 http://msj.sagepub.com
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research-article2014
MSJ0010.1177/1352458514546786Multiple Sclerosis JournalL Grau-López, A Teniente-Serra
MULTIPLE SCLEROSIS MSJ JOURNAL
Short Report
Similar biological effect of high-dose oral versus intravenous methylprednisolone in multiple sclerosis relapses
Multiple Sclerosis Journal 2015, Vol. 21(5) 646–650 DOI: 10.1177/ 1352458514546786 © The Author(s), 2014. Reprints and permissions: http://www.sagepub.co.uk/ journalsPermissions.nav
L Grau-López, A Teniente-Serra, M Tintoré, A Rovira, L Ramió-Torrenta, L Brieva, A Saiz, A Cano, O Carmona, JV Hervás, EM Martínez-Cáceres and C Ramo-Tello
Abstract Our aim was to investigate differences in immune mechanisms in multiple sclerosis (MS) relapse, after high-dose oral methylprednisolone (oMP) or intravenous methylprednisolone (ivMP). We measured serum cytokines (IL-2, IL-4, IL-6, IL-10, IL-17, TNF-α and IFN-γ) in 39 of 49 MS patients with moderate-severe relapse, whom were treated with ivMP or oMP in a placebo-controlled, non-inferiority clinical trial. We assessed these cytokine levels at baseline and at 1 and 4 weeks post-treatment. The cytokine levels between oMP and ivMP were similar at any time. Proinflammatory cytokines (IL-6 and IFN-γ) were significantly decreased in both groups at week 1 (p = 0.05 / p = 0.03) and at week 4 (p = 0.04 / p = 0.05). This study provides further confirmatory evidence that oMP is not inferior to ivMP. Trial registration: clinicaltrials.gov identifier: NCT00753792
Keywords: Clinical trial, cytokines, dosage forms, methylprednisolone, multiple sclerosis, relapses Date received: 7 April 2014; accepted: 9 July 2014
Introduction Relapsing–remitting multiple sclerosis (RRMS) is a chronic inflammatory, demyelinating disease of the central nervous system (CNS) of unknown etiology. It is characterized by periods of neurological dysfunction (relapses), followed by periods of clinical remission. During relapses in multiple sclerosis (MS) there is lymphocyte activation, extravasation and infiltration into the CNS, together with activation of immunocompetent glial cells that leads to myelin destruction. The proinflammatory Type 1 helper T (Th1) cytokines tumor necrosis factor-α (TNF-α), interferon-γ (IFN-γ) and interleukin-2 (IL-2) are related to inflammation and tissue damage. The Th2 cytokines IL-10 and IL-4 contribute to suppression of disease activity.1,2 Administration of methylprednisolone (MP) shortens the recovery period following a MS relapse,3 through the inhibition of immune function.4,5 MP decreases proinflammatory cytokines (the chemokine CCL2, TNF-α and IL-6) in peripheral blood and cerebrospinal fluid (CSF) of
patients with MS relapse.6,7 An immediate (at 5 days), but not long-term (1 month), increase in anti-inflammatory cytokines (IL-10) is also reported.2,4 In keeping with the hypothesis investigated by other authors, oral MP (oMP) is not clinically nor radiologically inferior to intravenous MP (ivMP), and in that it is equally well-tolerated and safe,8–10 we conducted a Phase-IV, multicenter, double-blind, randomized, non-inferiority clinical trial, to compare bioequivalent high-dose oMP versus ivMP to treat MS relapses, and we provided confirmatory evidence that bioequivalent high-dose oMP is not clinically nor radiologically inferior to ivMP, and that it is equally well tolerated and safe.11 The objective of the current study was to investigate possible differences in immune mechanisms upon diagnosis of a MS relapse (baseline) and at both 1 and 4 weeks after initiation of treatment with either oMP (1250 mg/24 h) or ivMP (1000 mg/24 h) for a period of 3 days.
Correspondence to: Laia Grau-López Department of Neurosciences, Hospital Germans Trias i Pujol, C/ Canyet s/n 08916 Badalona, Spain. [email protected] L Grau-López A Teniente-Serra JV Hervás EM Martínez-Cáceres C Ramo-Tello Hospital Germans Trias i Pujol, Badalona, Spain/ Universitat Autònoma de Barcelona, Spain M Tintoré A Rovira Hospital Vall D’ Hebron, Barcelona, Spain L Brieva Hospital Arnau de Vilanova, Lleida, Spain L Ramió-Torrenta Hospital Dr Josep Trueta, Girona, Spain A Saiz Hospital Clinic, Barcelona, Spain A Cano Hospital de Mataró, Mataró, Spain O Carmona Hospital de Figueres, Figueres, Spain
646 http://msj.sagepub.com
Downloaded from msj.sagepub.com at UNIV NEBRASKA LIBRARIES on April 13, 2015
L Grau-López, A Teniente-Serra et al. Methods
p value of < 0.05 was considered to be statistically significant.
Patients We analyzed serum cytokines in 39 of 49 MS patients whom had agreed to participate in the immunological analysis from a Phase-IV, multicenter, double-blind, randomized clinical trial.11 There were no differences in clinical and radiological variables between patients who had accepted and patients who had denied to participate in the immunological analysis. The study included adults whom met the 2005 McDonald criteria for RRMS and had experienced a relapse. The inclusion criteria were: (a) An age of 18 to 59 years; (b) An Expanded Disability Status Scale (EDSS) score of 0 to 5.0, prior to relapse; (c) Recent onset (< 15 days) of relapse; and (d) One month of clinical stability, prior to relapse. The exclusion criteria were: isolated clinical syndrome, progressive MS, use of steroids during the previous 3 months and use of natalizumab or immunosuppressive therapy at any time (concomitant treatment with interferon and glatiramer acetate was allowed). The trial protocol was approved by the ethics committees of all the participating centers and the trial was appropriately registered (ClinicalTrials.gov; no. NCT00753792). We obtained written informed consent before randomization, in all cases. We collected 10 ml blood samples at baseline, and at weeks 1 and 4, after treatment with oMP (n = 20) or ivMP (n = 19).
Results There were no differences in cytokine levels after treatment with oMP versus ivMP No significant differences were observed in cytokine levels between patients treated with oMP versus ivMP at baseline, week 1 and week 4 (Table 1). Treatment with either ivMP or oMP induced a decrease in proinflammatory cytokines Proinflammatory cytokines (IL-6 and IFN-γ) were significantly reduced at week 1 and week 4 post-treatment initiation in all patients (p = 0.05 and p = 0.05), as seen in Figure 1(a) and Figure 1(b); and in patients treated with ivMP (n = 19; p = 0.05 and p = 0.03) and oMP (n = 20; p = 0.04 and p = 0.05), respectively (Figure 1(c) and Figure 1(d)). Serum levels of IL-2, IL-17 and TNF-α were below the detection limit in most patients; but in those cases in which IL-17 (n = 6) and TNF-α (n = 8) were detected, a decrease was found with respect to baseline (Figure 1(e) and Figure 1(f)).Levels of anti-inflammatory cytokines (IL-10 and IL-4) were not significantly altered by treatment (n = 39; p = 0.26 and p = 0.12) (Figure 1(g) and Figure 1(h)).
Analysis of cytokine production We obtained the serum from blood after 10 minutes of centrifugation at 1800 rpm, and then froze the sera at − 80ºC, until our analysis for seven cytokines (IL-2, IL-4, IL-6, IL-10, IL-17, TNF-α and IFN-γ). Cytokine levels were determined at baseline and at weeks 1 and 4. Cytokine levels were quantified in undiluted sera, using a cytokine bead array kit (BD Biosciences), and then analyzed by flow cytometry (FACSCanto II, BD Biosciences). The detection limits were set: 1.07 pg/ ml for IL-2, 0.85 pg/ml for IL-4, 0.77 pg/ml for IL-6, 0.87 pg/ml for IL-10, 0.74 pg/ml for IL-17, 0.74 pg/ ml for TNF-α and 0.67 pg/ml for IFN-γ.
Discussion This study provides immunological evidence that bioequivalent high-dose oMP is not different to ivMP in the treatment of MS relapses. Previously, we demonstrated that oMP was not inferior to ivMP, in terms of reducing the patients’ EDSS scores and magnetic resonance imaging (MRI) lesions after 4 weeks, in patients with MS relapses, and we also showed that it was equally well tolerated and safe.11 Here we have shown, in a subset of patients from the trial, that there were no significant differences in serum cytokine levels between both dosage forms, before and 1 and 4 weeks after treatment, providing evidence that oMP is not mechanistically different to ivMP in the treatment of MS relapses. To our knowledge, this is the first study comparing cytokine levels after oMP and ivMP treatment in MS patients.
Statistical analysis We compared the cytokine levels between the two treatments groups, using unpaired Student’s t test. A
In our study, basal levels of anti-inflammatory cytokines (IL-4 and IL-10) were not modified after treatment with oMP or ivMP, at 1 week nor at 4 weeks. Despite the effect of MP on cytokines has been widely
http://msj.sagepub.com 647
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Multiple Sclerosis Journal 21(5) Table 1. Cytokine levels (pg/ml) in both treatment groups.
ivMTP (n = 19)
oMTP (n = 20)
p
IL-2a IL-4 IL-6 IL-10 TNFαa IFNγ IL-17a Week 1 (t = 1) IL-4 IL-6 IL-10 IFNγ
15.5 (SD 14.4) 2.2 (SD 0.8) 2.75 (SD 1.34) 2.45 (SD 0.62) 2.38 (SD 1) 5.37 (SD 11.45) 82.9 (SD 101.7)
14.3 (SD 18.6) 1.9 (SD 0.7) 3.16 (SD 2.8) 1.63 (SD 0.43) 2.4 (SD 0.39) 6.86 (SD 17) 78.9 (SD 115)
0.44 0.73 0.11 0.46 0.44 0.55 0.92
2.31 (SD 0.75) 2.3 (SD 0.76) 2.08 (SD 0.2) 2.12 (SD 0.67)
2.17 (SD 0.46) 1.87 (SD 0.5) 1.21 (SD 0.46) 1.8 (SD 0.51)
0.08 0.13 0.6 0.43
ivMP (n = 19)
oMP (n = 20)
p
Week 4 (t = 2) IL-4 IL-6 IL-10 IFNγ
2.22 (SD 0.58) 1.97 (SD 0.43) 1.49 (SD 0.15) 2.16 (SD 1.22)
1.97 (SD 0.4) 1.74 (SD 1.81) 1.38 (SD 0.77) 1.74 (SD 0.48)
0.12 0.08 0.26 0.07
Basal (t = 0)
aTNFα, IL17 and IL2 were below detection levels of the technique used, at Week 1 and Week 4, in n = 31, 33 and 39 patients, respectively. IFN: interferon; IL: interleukin; ivMP: intravenous methylprednisolone; oMP: oral methylprednisolone; TNF: tumor necrosis factor.
studied, only a few studies demonstrate a clear effect on anti-inflammatory cytokines2,12; however, the effect of MP treatment on pro-inflammatory cytokines in MS relapses has been demonstrated more extensively.6,13 We also observed a decrease in pro-inflammatory cytokine production (IL-6 and IFN-γ) at both 1 and 4 weeks post-treatment. Decreases in proinflammatory cytokines are easier to detect than antiinflammatory cytokines, following treatment with steroids, because patients with MS typically experience a clear, detectable increase in pro-inflammatory, but not anti-inflammatory, cytokines during relapse.6 IFN-γ has a great impact on the regulation of the immune response: It stimulates the differentiation of Th1 cells, inhibits the differentiation of Th2 cells and activates cytotoxic T cells. Furthermore, IFN-γ influences antibody production and stimulates macrophages to produce TNF-α, IL-1, IL-6 and IL-8. We have demonstrated that MP treatment of relapses induces immediate post-treatment and short-term decrease in IFN-γ that could partly account for the clinical and radiological improvements observed in MS patients.14
All of the patients in our series were treated with steroids. A comparison of cytokine levels between treated and untreated patients would be useful for determining cytokine changes over time, but this is generally not feasible, as steroid treatment needs to be implemented in most cases of moderate or severe relapse. In conclusion, we observed no differences in cytokine levels between patients treated with oMP or ivMP, providing further support showing that the two modes of administration are equivalent. These findings support the use of oMP to treat MS relapses, to spare patients from more invasive, less convenient and more costly medical procedures. Conflict of interest None declared. Funding This work was supported in part by the Ministry of Health of Spain (grant no. EC07/90278) and by Biogen Idec.
648 http://msj.sagepub.com
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L Grau-López, A Teniente-Serra et al.
Figure 1. Figure 1(a) IL-6 levels decreased at week 1 (p = 0.05) and week 4 (p = 0.05) in all patients (n = 39); (b) IFN-γ levels decreased at week 1 (p = 0.05) and week 4 (p = 0.02) in all patients (n = 39); (c) IL-6 levels decreased at week 1 (p = 0.05) and week 4 (p = 0.04) in patients treated with ivMP (n = 19) and oMP (n = 20); (d) IFN-γ levels decreased at week 1 (p = 0.03) and week 4 (p = 0.05) in patients treated with ivMP (n = 19) and oMP (n = 20); (e) IL-17 levels decreased at week 1 and week 4 in patients treated with ivMP (n = 3) and oMP (n = 3); (f) TNF-α decreased at week 1 and week 4 in patients treated either ivMP (n = 4) or oMP (n = 4); (g) there were no significant changes in IL-10 levels (p = 0.26) nor (h) IL-4 levels (p = 0.12) after treatment with either ivMP or oMP (n = 39). http://msj.sagepub.com 649
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Multiple Sclerosis Journal 21(5)
References 1. Cannella B and Raine CS. The adhesion molecule and cytokine profile of multiple sclerosis lesions. Ann Neurol 1995; 37: 424–435. 2. Gayo A, Mozo L, Suarez A, et al. Glucocorticoids increase IL-10 expression in multiple sclerosis patients with acute relapse. J Neuroimmunol 1998; 85: 122–130. 3. Pozzilli C, Marinelli F, Romano S, et al. Corticosteroid treatment. J Neurol Sci 2004; 223: 47–51. 4. Rentzos M, Nikolau C, Rombos A, et al. Effect of treatment with methylprednisolone on the serum levels of IL-12, IL-10 and CCL2 chemokine in patients with multiple sclerosis in relapse. Clin Neurol Neurosurg 2008; 110: 992–996. 5. Martinez-Cáceres E, Barrau MA, Brieva L, et al. Treatment with methylprednisolone in relapses of multiple sclerosis patients: Immunological evidence of immediate and short-term but not long-lasting effects. Clin Exp Immunol 2002; 127: 165–171. 6. Baraczka K, Nekam K, Pozsonyi T, et al. Investigation of cytokine (tumor necrosis factoralpha, interleukin-6, interleukin-10) concentrations in the cerebrospinal fluid of female patients with multiple sclerosis and systemic lupus erythematosus. Eur J Neurol 2004; 11: 37–42. Visit SAGE journals online http://msj.sagepub.com
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7. Matsushita T, Tateishi T, Isobe N, et al. Characteristic cerebrospinal fluid cytokine/chemokine profiles in neuromyelitis optica, relapsing remitting or primary
progressive multiple sclerosis. PLoS One 2013; 8: e61835. 8. Alam SM, Kyriakides T, Lawden M, et al. Methylprednisolone in multiple sclerosis: A comparison of oral with intravenous therapy at equivalent high dose. J Neurol Neurosurg Psychiatry 1993; 56: 1219–1220. 9. Sharrack B, Hughes RA, Morris RW, et al. The effect of oral and intravenous methylprednisolone treatment on subsequent relapse rate in multiple sclerosis. J Neurol Sci 2000; 173: 73–77. 10. Martinelli V, Rocca MA, Annovazzi P, et al. A short-term randomized MRI study of high-dose oral vs intravenous methylprednisolone in MS. Neurology 2009; 73: 1842–1848. 11. Ramo-Tello C, Grau-López L, Tintoré M, et al. A randomized clinical trial of oral versus intravenous methylprednisolone for relapse of MS. Mult Scler 2014; 20: 717–725 12. So EY, Kim SH, Park HH, et al. Corticosteroid inhibits IL-4 signaling through down-regulation of IL4 receptor and STAT6 activity. FEBS Lett 2002; 518: 53–59. 13. Dufour A, Salmaggi A, La Mantia L, et al. Highdose methylprednisolone treatment-induced changes in immunological parameters in progressive MS patients. Int J Neurosci 1994; 75: 119–128. 14. Petermann F and Khorn T. Cytokines and effector T-cell subsets causing autoimmune CNS disease. FEBS Lett 2011; 585: 3747–3757.
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