Faculty Bibliography

Background: Ocrelizumab (OCR), a humanized, anti-CD20 antibody therapy for multiple sclerosis (MS), is given at 6-month intervals. Some patients on OCR report worsening of MS-related symptoms in the weeks leading up to their infusion ('wearing-off' phenomena), but there are no published reports quantifying symptom variation in relation to the timing of OCR infusions.
Objective(s): We will measure symptom burden using SymptoMScreen, NeuroQol and WPAI:MS at 3 points in each infusion cycle over 2 infusion cycles and also obtain Ocrelizumab concentration (PK), neurofilament light chain (NfL), B-cell subsets, and routine clinical labs prior to each infusion.
Aim(s): To quantitate change in symptom burden throughout the infusion cycle in OCR-treated MS patients and to determine which clinical and paraclinical variables correlate with symptom worsening.
Method(s): Prospective, observational, two-center study enrolled patients with relapsing and progressive forms of MS that are initiating OCR or who have been on OCR for >= 1 year (ClinicalTrials. gov Identifier: NCT04855617). All patients receive MS care at NYU MS Care Center (NYU) in New York, NY, or the Elliot Lewis MS Center for MS (ELC) in Wellesley, MA. Patients aged 18-80 and with EDSS scores between 0-7 are eligible for enrollment.
Result(s): 110 participants were enrolled and are actively followed in the study (55 from NYU/55 from ELC). At baseline visit, the mean age was 46.0+/-12.7 years; 64.6% were female; 31.8% were non-White; 20.0% were Hispanic/ Latino; disease duration was 12.6+/-9.6 years; OCR treatment duration was 2.8+/-1.0 years; mean EDSS was 3.3+/-2.1 (EDSS<4, n=69 (62.7%), EDSS>=4, n=41 (37.3%)). Breakdown by disease subtypes was: relapsing-remitting, n=68 (61.8%), secondary progressive, n=24 (21.8%), primary progressive, n=18 (16.4%). Among 58 patients who completed at least 2 questionnaires to date, the symptom burden, as assessed with the SymptoMScreen, was unchanged from week 4 post-infusion to week 12 post-infusion (p-values ranged from 0.2-0.9 for each of the 11 individual domains by Wilcoxon nonparametric test).
Conclusion(s): SymBOLS, designed to assess for the wearing-off effect in OCR-treated patients, has successfully enrolled 110 patients across two US sites. Preliminary data suggest there are no changes to symptom burden during the first half of the infusion cycle. Additional data regarding changes during the second half of the cycle as well as NeuroQoL and work productivity (WPAI) data will be presented

Background: Modern, highly efficient hemodialysis (HD) results in rapid decline of blood urea. Urea gradients across the blood-brain barrier (BBB) can drive water movements. A positive urea gradient, i.e. brain urea to plasma urea, can result in brain swelling and impair brain function. We explored the dialytic changes of urea in blood and cerebrospinal fluid (CSF) to better understand intradialytic osmotic gradients across the BBB and provide insights that support the development of brain-protective HD.
Method(s): Two HD patients (39 and 26 years old) with ventriculo-peritoneal (VP) shunts were enrolled into this one-week IRB-approved study with a Monday/Wednesday/ Friday dialysis schedule. CSF was collected via VP shunt tap 2 hrs before and 2 hrs after HD (Wednesday and Friday), and Tuesday and Thursday. Plasma samples were collected concurrently with CSF and during HD. In addition, the patients underwent test of executive function (Trail Making Test Part B; TMT B) and global cognitive function (Montreal Cognitive Assessment; MoCA) on Monday.
Result(s): Urea was removed efficiently from patients' blood by HD. While patient A showed a small post-HD plasma-to-CSF urea gradient, it was highly positive (~ 60 mg/dL) in patient B (Fig. 1). TMT B and MoCA score were normal for patient A but not patient B (TMT B 415 sec; TMT B error count: 2; MoCA score: 11).
Conclusion(s): Our patients showed very different post-HD plasma-to-CSF gradients. Theoretically, the positive gradient in patient B would favor intradialytic brain swelling. Patient B showed impaired neurological testing results which are not related to patient's pre-existing neurological conditions. We can only speculate if and to what extent trans-BBB water movements driven by dialytic urea dynamics may have impacted the patient's cognitive functions?. We believe that patient-specific levels of osmotic stress need to be considered when developing neuro-protective HD technologies

Introduction: Treatment of pediatric-onset multiple sclerosis (POMS) is challenging given the lack of safety and efficacy data in the pediatric population for many of the disease-modifying treatments (DMTs) approved for use in adults with MS. Data regarding the demographic features and clinical outcomes of POMS patients treated with these DMTs could help guide future treatment algorithms in this population. Objective/Aims: To describe the demographic features and clinical and radiologic course of POMS patients on the commonly used newer DMTs within the US Network of Pediatric MS Centers.
Method(s): This is an analysis of prospectively collected data from patients seen at 11 regional pediatric MS referral centers participating in the US Network of Pediatric MS Centers. POMS patients who initiated treatment between 10- & lt;18 years with dimethyl fumarate, fingolimod, natalizumab, rituximab or ocrelizumab were included and analyzed as individual cohorts.
Result(s): 168 patients on dimethyl fumarate, 96 on fingolimod, 151 on natalizumab, 166 on rituximab, and 37 on ocrelizumab met criteria for analysis. Mean age at DMT initiation ranged from 15.2-16.5 years (median EDSS from 1.0-2.0), with 96-100% of patients at or above Tanner Stage 2. Disease duration at time of initiation of index DMT ranged from 1.1-1.6 years, while treatment duration with the index DMT ranged from 1.1-2.2 years. Mean number of relapses in the year prior to initiating index DMT ranged from 0.4-1.0. Mean number of relapses while on index DMT ranged from 0.1-0.4. New T2 and enhancing lesions occurred in 77-88% and 55-73% of the patients, respectively, during the year prior to initiating index DMT. After initiating index DMT, new T2 and enhancing lesions occurred in 7-52% and 11-35% patients, respectively.
Conclusion(s): Though limited by relatively short treatment duration with the index DMTs, our data suggest clinical and MRI benefit in a large number of POMS patients, which can be used to guide future studies in this population

Objective: To examine antibody and T-cell responses to mRNAplatform COVID-19 vaccines in Ocrelizumab-treated MS patients over a 12-month period. Introduction: B-cell depletion with Ocrelizumab attenuates humoral responses to vaccines. The kinetics of humoral and cellular immune responses to COVID-19 vaccines in B-cell depleted MS patients has not been reported.
Method(s): VIOLA (NCT04843774) is an open-label, observational study enrolling 60 MS patients on Ocrelizumab from NYU and Rocky Mountain at the University of Colorado MS Centers. First vaccine dose occurred >=2 weeks after ocrelizumab infusion; second-dose >=8 weeks before the next infusion. Antibody responses to SARS-COV-2 spike proteins were assessed with Elecsys Anti-SARS-CoV-2 (Roche Diagnostics) and multiplex bead-based immunoassays. T-cell responses to SARS-CoV-2 Spike protein were assessed with IFNgamma ELISpot (Invitrogen) and TruCulture (Myriad RBM) and high-dimensional immunophenotyping. Samples are collected pre-vaccination and at 4, 12, 24, and 48-weeks post-vaccination.
Result(s): As of 7/15/2021, 52 subjects have been enrolled (39.7+/-10.0 years; 73% female; 47% non-white), of whom 47 were fully vaccinated (85% Pfizer, 15% Moderna). Anti-spike RBD antibody (Elecsys Anti-SARS-CoV-2) were available for pre- and post-vaccine timepoints for 15 patients. Pre-vaccine, 1/15 (7%) patients had detectable titers, while at 4-weeks postvaccine, 10/15 (66%) patients had detectible titers (mean for positives: 1189 U/ml; 5 patients had positive titers <25 U/ml). T-cell activation based on induced IFNgamma secretion (TruCulture) at baseline and 4-week post-vaccine timepoints were available for 13 patients, of whom 12 (92%) were increased (mean pre-vaccine: 24 pg/ml; mean post-vaccine: 366 pg/ml, two-tailed t-test, p=0.0032).
Conclusion(s): This prospective study of humoral and cellular immune responses to COVID-19 vaccines in Ocrelizumab-treated patients will generate data to help guide management of MS patients on anti-CD20 therapies. Early results suggest that 4-weeks post-vaccination nearly all Ocrelizumab-treated MS patients develop T-cell immunity and two-thirds showed evidence of humoral response. Additional 4-week and 12-week post-vaccination data will be presented

Introduction: Patients (pts) with paediatric multiple sclerosis (PedMS) have higher relapse rates and radiological activity, accumulating disability at a younger age vs adult-onset MS. There are challenges in conducting clinical trials for PedMS due to the low number of available pts and competing trials. Moreover, testing a new drug vs placebo or low efficacy control poses ethical concerns due to the high disease activity. Few Phase 3 studies have assessed the efficacy/safety of disease-modifying therapies (DMTs) in PedMS; PARADIGMS demonstrated a significant reduction in annualised relapse rate (ARR) for fingolimod vs interferon (IFN)beta-1a in PedMS. A large unmet need for new studied treatment options for PedMS remains.
Objective(s): To present the innovative Bayesian design of the Phase 3 NEOS study aimed to assess the efficacy and safety of ofatumumab and siponimod in PedMS.
Method(s): NEOS is a 2-year, randomised, 3-arm, double-blind, triple-dummy, parallel-group, multicentre, active-comparator, controlled global study comparing ofatumumab and siponimod vs fingolimod in the core part, followed by 2-5 years of an openlabel extension part. Eligibility criteria include pts aged 10 to <18 years, with Expanded Disability Status Scale score 0-5.5 who had experienced >=1 relapse in the last year or >=2 relapses in last 2 years or evidence of >=1 gadolinium-enhancing lesions on MRI within 12 months before randomisation. The primary objective is to demonstrate the non-inferiority (NI) of ofatumumab and siponimod vs fingolimod, assessed by ARR up to 2 years, and will be analysed using a Bayesian negative binomial regression model. This model incorporates information from historical studies on all 3 treatments to reduce the required sample size. The key secondary objective is to demonstrate superiority of ofatumumab and siponimod vs historical IFNbeta-1a data, assessed by ARR. Other endpoints include number of new/newly enlarging T2 lesions on MRI per year, serum neurofilament light chain and safety/tolerability. Randomisation of ~180 pts (n=60 per arm) will provide >80% power for the demonstration of NI (margin of 2.0) for each test treatment vs fingolimod.
Result(s): Study design will be presented at the congress.
Conclusion(s): The innovative NEOS study design does not include placebo or low efficacy controls and thus offers PedMS pts a DMT already shown to be highly effective in adults. NEOS has the potential to bring 2 new future treatment options-ofatumumab and siponimod for PedMS

Objective: To compare humoral and T-cell responses to COVID- 19 vaccines in 400 MS patients who were on Ocrelizumab ('OCR') v. other disease-modifying therapies ('non-OCR') at the time of vaccination. Introduction: Peripheral B-cell depletion with anti-CD20 therapies attenuates humoral responses to vaccines. Whether immune responses to COVID-19 vaccines differ between B-cell depleted and non-B cell depleted MS patients is not known.
Method(s): Consecutive MS patients from NYU MS Care Center were invited to participate if they completed COVID-19 vaccination >=6 weeks previously. Immune testing included anti-spike RBD antibody (Elecsys Anti-SARS-CoV-2) (Roche Diagnostics); multiplex bead-based immunoassays of antibody-responses to SARS-COV-2 spike proteins; T-cell responses to SARS-CoV-2 Spike protein using IFNgamma enzyme-linked immune-absorbent spot (Invitrogen) and TruCulture (Myriad RBM) assays; high dimensional immunophenotyping; and live virus immunofluorescencebased microneutralization assay.
Result(s): As of 7/15/2021, 105 MS subjects were enrolled (mean age: 40.5 years; 76% female; 41% non-white; 38% on OCR; 12% with prior COVID-19 infection). 95% were fully vaccinated with mRNA vaccines (Pfizer/Moderna); 5% - with adenovirus-based vaccine (Johnson&Johnson). Median time from sample collection to last vaccine was 79 days. Positive Elecsys Anti-SARS-CoV-2 Ab titers post-vaccine were detected in 11/37 (30%) in OCR (mean level: 702 U/mL among seropositives) and 54/54 (100%) patients in non-OCR (mean level: 2310 U/mL; p<0.0001). Positive response by multiplex assay (threshold of 'positive' defined as 2 SD below the mean for the non-OCR) were detected in 10/27 (37%) OCR and 29/31 (94%) non-OCR (p<0.00001). T-cell activation based on induced IFNgamma secretion (TruCulture) was detected in 20/25 (80%) OCR and 16/19 (84%) non-OCR patients (p=0.71).
Conclusion(s): Preliminary results suggest robust T-cell immune response to SARS-CoV2 vaccines in approximately 80% of both OCR and non-OCR MS patients. Antibody responses were markedly attenuated in OCR compared to non-OCR group. Updated results will be presented

Introduction: Mucopolysaccharidosis VII (MPS VII) is an ultra-rare, autosomal recessive, debilitating, progressive lysosomal storage disease caused by beta-glucuronidase (GUS) enzyme deficiency. Vestronidase alfa (recombinant human GUS) enzyme replacement therapy is approved in the United States, Europe, and Latin America for the treatment of MPS VII.
Method(s): The disease monitoring program (DMP) is an ongoing, multicenter observational study collecting standardized real-world data from patients with MPS VII (N~35) treated with vestronidase alfa or with any other management approach. Investigational sites are centers with expertise in the treatment of mucopolysaccharidosis. Data will be collected for up to 10 years and include demographics, clinical history, clinical characteristics, cognition, mobility, skeletal disease, pulmonary function, patient/caregiver-reported healthrelated quality of life, and long-term vestronidase alfa safety and effectiveness. Data are monitored and recorded in compliance with Good Clinical Practice (GCP) guidelines. Annual individual patient reports will be provided to respective patients and caregivers.
Result(s): As of May 31, 2020, sixteen patients are enrolled: 11 prescribed vestronidase alfa and 5 not treated with vestronidase alfa. Median (min, max) age at MPS VII diagnosis was 4.1 (0.1, 12.0) years. Six patients (38%) had a history of non-immune hydrops fetalis. Four patients who reached one year of treatment in the DMP had a mean (SD) decrease of 1.18 (0.35) g GAG/g creatinine in dermatan sulfate uGAG excretion from the parent (clinical) study baseline (88% reduction). Three serious adverse events (SAEs) unrelated to vestronidase alfa occurred: recurrent cervical spinal stenosis, corneal opacity, and parainfluenza virus infection. One SAE, intermittent hypotension, was assessed as an infusion-associated reaction to vestronidase alfa. All SAEs were consistent with the known safety profile of vestronidase alfa. No deaths were reported.
Conclusion(s): Reductions in uGAG demonstrate ongoing effectiveness of vestronidase alfa at Year 1 of the DMP. No newsafety concernswere identified, and all patients continue on-study. Enrollment is ongoing.
Copyright 2021 Elsevier Inc. All rights reserved

Background/Purpose: Interferon (IFN)-alpha contributes to susceptibility and severe manifestations in systemic lupus erythematosus (SLE). The PRKG1 rs7897633 variant has been previously identified as the top hit in European ancestry patients with SLE and high IFN-alpha compared to those with low circulating IFN activity. However, the mechanisms by which PRKG1 polymorphisms impact the immune system remain unknown. PRKG1 codes for the cGMP-dependent protein kinase I (PKGI). Activation of PKGI leads to VASP phosphorylation, and the inhibition of RhoA and Rho-associated kinases (ROCK). A subgroup of patients with SLE exhibit higher ROCK activity in circulating immune cells compared to healthy controls. ROCK inhibition decreases IFN-alpha production and ameliorates disease in murine models of lupus. Accordingly, we aimed to assess whether the PRKG1 gene variant was associated with decreased gene expression and activity of PRKG1, hyperactivation of the ROCK pathway, and altered response to type I IFN.
Method(s): We used B lymphoblastoid cell lines (LCL) derived from healthy subjects of European ancestry (Coriell repositories) homozygous (AA or CC) and heterozygous (AC) at the rs7897633 SNP for all experiments. Gene expression of PRKG1, RHOA, and ROCK was assessed by RT-qPCR using gene-specific primers, normalized by GAPDH, and measured by the 2-DELTADELTACT method. IFN score at baseline and after treatment of LCL with increasing doses of IFN-alpha was measured by quantifying 3 canonical IFN-stimulated genes (IFIT1, MX1 and PKR) and summing to generate a score reflecting the degree of IFN-induced gene expression in the cells. Abundance of PKGI and VASP phosphorylation (as a surrogate of PKGI activity) were determined by Western blotting at baseline and after treatment with a PKGI agonist. ROCK2 enzymatic activity was performed by a colorimetric assay (Cell Biolabs). Unstimulated and stimulated cells were compared among PRKG1 genotype categories. Statistically significant differences were determined by Mann Whitney U test or sum-of-squares F test, as appropriate.
Result(s): PRKG1 expression was lower in the homozygous AA genotype as compared with the homozygous CC genotype in LCL (p< 0.05). In contrast, ROCK expression was higher in LCL with the AA rs7897633 genotype (p< 0.05). Compared to LCL with the homozygous AA variant of rs7897633, homozygous CC LCL have greater abundance of PKGI, phosphorylated VASP/total VASP ratio in response to a PKGI agonist (indicating increased PKGI activity), and lower baseline ROCK activity (sum-of-squares F test, p< 0.05). The IFN score was significantly higher in the homozygous CC allele LCL, both at baseline and with increasing doses of IFN-alpha, suggesting increased sensitivity to type I IFN (p< 0.05).
Conclusion(s): PRKG1 AA genotype associates with lower PRKG1 and higher ROCK mRNA expression, decreased PKGI abundance and activity, and greater ROCK baseline activity. In contrast, the rs7897633 CC genotype is associated with increased response to IFNalpha. Overall, these findings suggest an important role of genetic variation at PRKG1 in modulating the RhoA-ROCK pathway and regulating response to type I IFNs in LCL, which may have therapeutic implications in patients with SLE