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I read the editorial by Dr G Giovannoni and colleagues1 with great interest. I have, however, to report a minor error concerning the list of the excipients of the Rebif reported in their table 1. In the table the authors reported the following excipients: mannitol, HSA, sodium acetate, acetic acid, sodium chloride. Actually, as you can check in the summary of product characteristics published from EMEA (www.emea.eu.int) on 29 March 1999, in the list of excipients sodium chloride is absent, whereas sodium hydroxide is present.
We would like to thank Dr Ortenzi for pointing out our transcription error in relation to the excipients of Rebif™ in table 1 of our editorial.1
We agree with Polman and colleagues that recent comparisons show that the more immunogenic higher dose interferon β (IFNβ) preparations are more efficacious than the lower dose less immunogenic preparations over 24 month2 and six month3 periods of observation. However, as discussed in our editorial, the development of neutralising antibodies and their effects on the clinical efficacy of IFNβ are delayed. In the PRISMS study the effect of neutralising antibodies on clinical efficacy only became apparent in years 3–4.4 In the pivotal IFNβ-1b study an effect on relapse rate was only observed in the 19–24 and 25–30 month epochs.5 Hence we would argue that these comparative studies2,3 are simply too short, and in the case of the INCOMIN trial underpowered (n = 188),2 to demonstrate an effect of neutralising antibodies on clinical efficacy. It is therefore impossible to extrapolate the significant short term differences shown in these studies beyond the periods of observation reported.
Because of regression to mean and the well documented tendency for the relapse rate to decrease with disease duration, it is not possible to draw any meaningful conclusions from a comparison of the relapse rate in years 1–2 and years 3–4 from the PRISMS extension study.4,6 In addition to the impact of neutralising antibodies on relapse rate, the PRISMS extension study clearly shows—using the more objective T2 lesion volume or burden of disease—that the average annualised increase in lesion volume over four years in the neutralising antibody positive (NAB+) patients is similar to the increase in the annualised lesion volume in the placebo treated patients in the first two years of the study (NAB+ 4.4% v placebo 5.45%).4,6 Similarly, in the IFNβ-1b study,5 the annualised relapse rate of NAB+ patients is identical to patients on placebo (1.08 v 1.06). In the IFNβ-1a (Avonex™) trial,7 the impact of neutralising antibodies was limited to MRI outcomes. The failure of neutralising antibodies to have an effect on disease progression and relapse rate in this study probably reflects the size and duration of follow u, as the study was terminated prematurely. It is these data from the pivotal relapsing multiple sclerosis clinical trials, and other studies on in vivo markers of IFNβ activity discussed in our editorial, that we use to support our statement that “interferon β has little if any clinical and MRI efficacy in the presence of neutralising antibodies.”
Data on the impact of neutralising antibodies in secondary progressive multiple sclerosis (SPMS) trials is less clear. This is to be expected, however, as the efficacy of IFNβ on disease progression—the primary outcome measure in SPMS trials—is limited and hence it would be difficult to demonstrate a significant impact on neutralising antibodies on the primary outcome measure when the actual therapeutic intervention itself is only marginally effective.8,9 It would be very surprising if neutralising antibodies had a significant impact on disease progression, as none of the trials is powered to detect an effect of neutralising antibodies on this outcome. For example, in the European SPMS study, 100/360 (28%) of IFNβ-1b treated patients became NAB+ (titre > 20) over the course of the trial.10 Taking a conservative approach by applying the results from the trial,8,10 and assuming that NAB+ patients behave as if they are on placebo and NAB− patients behave like the original IFNβ-1b treated cohort, one would expect 49.8% of the 100 NAB+ patients to progress over three years, compared with 38.9% of the 260 NAB− patients. At the same level of significance (0.029) from the original study, a two sided test would only have a 35% chance of detecting a significant difference between NAB+ and NAB− patients (Fisher’s exact test). Compare this to a power of 80% used in the design of the original study. This power calculation is an overestimate as it ignores the therapeutic effect observed before the development of neutralising antibodies, as evidenced in this study,10 which if taken into account has the potential to further reduce the power of the subanalysis. Polman and colleagues further reduce the power of the subanalysis by limiting the longitudinal study to “switchers”—that is, clinical responses are compared within individual patients during NAB− and NAB+ periods.10 This longitudinal approach reduces the number of patients available for analysis and potentially shortens the period of observation. A longitudinal approach would seem reasonable if there are no carryover therapeutic effects of IFNβ-1b treatment from the NAB− to NAB+ phase and if the follow up in the NAB+ phase is of sufficient duration to account for the delayed effects (24 to 48 months) of neutralising antibodies on clinical efficacy. In this study the mean follow up in the NAB+ phase would be on average too short (less than 24 months) for one to be confident of excluding a delayed effect of neutralising antibodies on disease progression. Despite the lack of power of these subanalyses, they produce some surprising results. In the cross sectional study there was a trend towards greater disease activity in the NAB+ group in the third year, and a significant percentage T2 volume change from baseline to year 1, year 2, and the last visit10; in the underpowered and potentially flawed longitudinal analysis there was no indication of an attenuation of treatment effects on disability progression but, surprisingly considering the lower relapse rate in secondary progressive multiple sclerosis, there was a robust effect on relapse rate.10
Another way of interpreting the European SPMS NAB data as presented by Polman and colleagues is that the much higher dose of IFNβ-1b (875 μg/week) given in that study, in comparison with the lower licensed doses of IFNβ-1a (30–132 μg/week), acted to quench some of the neutralising activity of the antibodies.10 Similarly, the higher doses may be responsible for inducing high dose tolerance in a subset of the patients. These phenomena are well observed with other biologicals in which the read-outs are more objective than in multiple sclerosis—for example, coagulation in anti-factor VIII and glucose levels in anti-insulin antibody positive patients.
Polman and colleagues have misinterpreted our recommendations.1 We do not recommend routine screening of neutralising antibodies at present, nor the switching of treatments in NAB+ patients unless clinically justified, nor aggressive strategies to reduce or reverse the development of neutralising antibodies.1 We simply state that further research is necessary to assess whether these strategies are appropriate. Polman and colleagues’ concluding statement that treatment decisions should be based on clinical grounds rather than on neutralising antibody titres is entirely in keeping with our recommendations.1
We disagree with Polman and colleagues’ statement that “the clinical impact of neutralising antibodies to interferon β during treatment of multiple sclerosis may be more limited and more transient than suggested in the editorial.” Short to intermediate term data (< 4 years) from the relapsing multiple sclerosis studies discussed above4,5,7 do not support this claim, and long term clinical data (> 4 years) on the effects of transient neutralising antibodies on the therapeutic efficacy of IFNβ-1b do not exist to support the latter half of their claim. In addition, evidence is yet to surface on whether or not the phenomenon of transient high titre neutralising antibodies occurs to a similar degree in patients treated with IFNβ-1a; therefore the latter half of their statement, if true, may not be applicable to patients treated with IFNβ-1a.
In conclusion, clinicians cannot ignore the issue of neutralising antibodies, particularly in view of the evidence from other fields of medicine in which neutralising antibodies reduce or inhibit the efficacy of a wide range of biologicals, including type I interferons. Why should interferon treatment in multiple sclerosis be any different?
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