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Vitamin D far better than fingolimod in reducing MS relapse rate

Wondered about the characteristics of a drug which was approved by the FDA Sept 2010 to reduce the MS relapse rate.

Compared to vitamin D, Fingolimod:

  • is far less effective
  • is far more expensive
  • has major side-effects (2 people died!)

Overview of MS and Vitamin D at VitaminDWiki

Example: peer-reviewed paper found MS relapse rate for children was 34% less for every extra 10 ng/ml of vitamin D

It is a shame that so much money is being spent by big pharma on drugs which are not nearly as good as vitamin D in reducing MS relapse.

But, vitamin D cannot be patented - or can it? Noticed a patent application of MS and vitamin D Sept 2010

Category: Multiple Sclerosis 84 items as of Sept 2010

Overview at VitaminDWiki of MS

The following are a few of the abstracts on fingolimod and MS from PubMed

Also, there is one PDF attached to this Wiki Page

Treating multiple sclerosis with fingolimod or intramuscular interferon.

MS and Expert Opin Pharmacother. 2010 Aug;11(11):1957-60.
Pozzilli C, Prosperini L, Borriello G.
La Sapienza University, S. Andrea Hospital, Multiple Sclerosis Centre, Department of Neurological Sciences, Viale dell'Università, 30, 00185 Rome, Italy. carlo.pozzilli at uniroma1.it

The 12-month, double-blind TRANSFORMS study compared two dose regimens of oral fingolimod (0.5 and 1.25 mg/day) with intramuscular (i.m.) interferon beta-1a (IFN-beta-1a) administered once weekly at dosage of 30 microg in a study population of 1292 patients with relapsing remitting multiple sclerosis. Both doses of fingolimod were shown to be superior to i.m. IFN-beta-1a in reducing relapse rate and disease activity as detected by magnetic resonance imaging, while no significant effect on disability progression was observed.

Although about 90% of patients completed the study, a greater proportion receiving a higher dose of fingolimod discontinued treatment because of adverse events, such as herpes virus infections (fatal in two patients assigned to higher dose), dose-dependent bradyarrhytmias and lymphopenia, transient macular edema, skin cancer and liver enzyme increase. Because of these safety concerns, a long-term evaluation is required to define the risk-benefit ratio. The TRANSFORMS study clearly showed a superior efficacy of oral fingolimod over i.m. IFN-beta-1a, but it is still uncertain whether oral fingolimod could be used as first-line treatment, or as an alternative treatment for patients who have failed immunomodulating therapy. PMID: 20426705

Fingolimod for relapsing multiple sclerosis: an update.

Expert Opin Pharmacother. 2010 May;11(7):1183-96.
Horga A, Castilló J, Montalban X.
Multiple Sclerosis Centre of Catalonia (CEM-Cat), Vall d'Hebron University Hospital, Passeig Vall d'Hebron, 119-129, 08035 Barcelona, Spain. ahorga at cem-cat.org

IMPORTANCE OF THE FIELD: Multiple sclerosis (MS) is the most common inflammatory demyelinating disease of the CNS. There is a large unmet need for new disease-modifying therapies with improved convenience, safety and efficacy. Fingolimod is an oral sphingosine-1-phosphase (S1P) receptor modulator under clinical investigation for the treatment of relapsing-remitting and primary progressive MS.

AREAS COVERED IN THIS REVIEW: This review provides an update on the mechanism of action, pharmacological properties and efficacy and safety of fingolimod in patients with relapsing MS, with a particular emphasis on clinical trials.

WHAT THE READER WILL GAIN: The reader will gain a comprehensive overview of the mechanism of action of fingolimod, particularly how the drug inhibits lymphocyte egress from secondary lymphoid organs by modulation of S1P receptors, and its pharmacokinetic and pharmacodynamic properties. Results from Phase II studies and pivotal Phase III trials of fingolimod for relapsing MS are discussed in depth.

TAKE HOME MESSAGE: Randomized clinical trials have demonstrated the superior efficacy of fingolimod in reducing relapse rates and MRI measures of disease activity, as compared with placebo and intramuscular IFN-beta-1a. Fingolimod also lowered the risk of disability progression compared with placebo. Adverse events included bradycardia and atrioventricular block, respiratory and herpesvirus infections, increased liver enzyme levels, hypertension and macular edema. Fingolimod 0.5 mg seems to provide the best risk-benefit ratio. PMID: 20367536

A placebo-controlled trial of oral fingolimod in relapsing multiple sclerosis.

N Engl J Med. 2010 Feb 4;362(5):387-401. Epub 2010 Jan 20.
Kappos L, Radue EW, O'Connor P, Polman C, Hohlfeld R, Calabresi P, Selmaj K, Agoropoulou C, Leyk M, Zhang-Auberson L, Burtin P; FREEDOMS Study Group.
Collaborators (171)
Department of Neurology, University Hospital, University of Basel, Switzerland. lkappos at uhbs.ch

BACKGROUND: Oral fingolimod, a sphingosine-1-phosphate-receptor modulator that prevents the egress of lymphocytes from lymph nodes, significantly improved relapse rates and end points measured on magnetic resonance imaging (MRI), as compared with either placebo or intramuscular interferon beta-1a, in phase 2 and 3 studies of multiple sclerosis.

METHODS: In our 24-month, double-blind, randomized study, we enrolled patients who had relapsing-remitting multiple sclerosis, were 18 to 55 years of age, had a score of 0 to 5.5 on the Expanded Disability Status Scale (which ranges from 0 to 10, with higher scores indicating greater disability), and had had one or more relapses in the previous year or two or more in the previous 2 years. Patients received oral fingolimod at a dose of 0.5 mg or 1.25 mg daily or placebo. End points included the annualized relapse rate (the primary end point) and the time to disability progression (a secondary end point).

RESULTS: A total of 1033 of the 1272 patients (81.2%) completed the study. The annualized relapse rate was 0.18 with 0.5 mg of fingolimod, 0.16 with 1.25 mg of fingolimod, and 0.40 with placebo (P<0.001 for either dose vs. placebo). Fingolimod at doses of 0.5 mg and 1.25 mg significantly reduced the risk of disability progression over the 24-month period (hazard ratio, 0.70 and 0.68, respectively; P=0.02 vs. placebo, for both comparisons). The cumulative probability of disability progression (confirmed after 3 months) was 17.7% with 0.5 mg of fingolimod, 16.6% with 1.25 mg of fingolimod, and 24.1% with placebo. Both fingolimod doses were superior to placebo with regard to MRI-related measures (number of new or enlarged lesions on T(2)-weighted images, gadolinium-enhancing lesions, and brain-volume loss; P<0.001 for all comparisons at 24 months).

Causes of study discontinuation and adverse events related to fingolimod included bradycardia and atrioventricular conduction block at the time of fingolimod initiation, macular edema, elevated liver-enzyme levels, and mild hypertension.

CONCLUSIONS: As compared with placebo, both doses of oral fingolimod improved the relapse rate, the risk of disability progression, and end points on MRI. These benefits will need to be weighed against possible long-term risks. (ClinicalTrials.gov number, NCT00289978.) PMID: 20089952

Fingolimod: a novel immunosuppressant for multiple sclerosis.

Ann Pharmacother. 2007 Oct;41(10):1660-8. Epub 2007 Sep 4.
Brown BA, Kantesaria PP, McDevitt LM.
Partners Multiple Sclerosis Center, Brookline, MA 02445, USA. bbrown8 at partners.org

OBJECTIVE: To review the pharmacology, pharmacokinetics, efficacy, and safety of fingolimod, a novel immune modulator.

DATA SOURCES: Information was obtained through a MEDLINE search (1966-February 2007) and from published abstracts. Search terms included fingolimod, FTY720, FTY-720, and sphingosine-1-phosphate receptor agonist.

STUDY SELECTION AND DATA EXTRACTION: All English-language studies and abstracts pertaining to fingolimod were considered for inclusion. Preference was given to human data.

DATA SYNTHESIS: Fingolimod is the first in a new class of immune modulators known as the sphingosine-1-phosphate receptor agonists. It is administered orally once daily and causes a dose-related reduction in the number of circulating lymphocytes by preventing their egress from secondary lymph organs, but it does not alter T-cell activation or proliferation. Bradycardia and lymphopenia are the most common adverse effects. Clinical trials have evaluated the efficacy of fingolimod in renal transplantation and multiple sclerosis (MS). Further research for renal transplantation will not take place, but Phase 3 studies in MS are underway, as Phase 2 study results are favorable.

CONCLUSIONS: Due to its distinct mechanism of action and its oral administration, fingolimod may be a useful therapeutic option for patients with relapsing forms of MS. More data are needed to assess the safety and clinical utility of fingolimod. PMID: 17785617

Oral fingolimod (FTY720) for relapsing multiple sclerosis.

N Engl J Med. 2006 Sep 14;355(11):1124-40.
Kappos L, Antel J, Comi G, Montalban X, O'Connor P, Polman CH, Haas T, Korn AA, Karlsson G, Radue EW; FTY720 D2201 Study Group.
Department of Neurology, University Hospital, Basel, Switzerland. lkappos at uhbs.ch

BACKGROUND: Fingolimod (FTY720) is a new oral immunomodulating agent under evaluation for the treatment of relapsing multiple sclerosis.

METHODS: We randomly assigned 281 patients to receive oral fingolimod, at a dose of 1.25 mg or 5.0 mg, or a placebo once daily, and we followed these patients for 6 months with magnetic resonance imaging (MRI) and clinical evaluations (core study, months 0 to 6). The primary end point was the total number of gadolinium-enhanced lesions recorded on T(1)-weighted MRI at monthly intervals for 6 months. In an extension study in which the investigators and patients remained unaware of the dose assignments (months 7 to 12), patients who received placebo underwent randomization again to one of the fingolimod doses.

RESULTS: A total of 255 patients completed the core study. The median total number of gadolinium-enhanced lesions on MRI was lower with 1.25 mg of fingolimod (1 lesion, P<0.001) and 5.0 mg of fingolimod (3 lesions, P=0.006) than with placebo (5 lesions). The annualized relapse rate was 0.77 in the placebo group, as compared with 0.35 in the group given 1.25 mg of fingolimod (P=0.009) and 0.36 in the group given 5.0 mg of fingolimod (P=0.01). For the 227 patients who completed the extension study, the number of gadolinium-enhanced lesions and relapse rates remained low in the groups that received continuous fingolimod, and both measures decreased in patients who switched from placebo to fingolimod. Adverse events included nasopharyngitis, dyspnea, headache, diarrhea, and nausea. Clinically asymptomatic elevations of alanine aminotransferase levels were more frequent with fingolimod (10 to 12%, vs. 1% in the placebo group). One case of the posterior reversible encephalopathy syndrome occurred in the 5.0-mg group. Fingolimod was also associated with an initial reduction in the heart rate and a modest decrease in the forced expiratory volume in 1 second.

CONCLUSIONS: In this proof-of-concept study, fingolimod reduced the number of lesions detected on MRI and clinical disease activity in patients with multiple sclerosis. Evaluation in larger, longer-term studies is warranted. (Clinicaltrials.gov numbers, NCT00333138 core study and NCT00235430 ClinicalTrials.gov extension.). PMID: 16971719

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