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      Is Open Access

      Sativex in resistant multiple sclerosis spasticity: Discontinuation study in a large population of Italian patients (SA.FE. study)

      research-article
      1 , 2 , 3 , 4 , 5 , 6 , 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 1 , 1 , * , on behalf of the SA.FE. study group
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          Abstract

          Background

          The approval of Sativex for the management of multiple sclerosis (MS) spasticity opened a new opportunity to many patients. In Italy, the healthcare payer can be fully reimbursed by the involved pharma company with the cost of treatment for patients not responding after a 4 week (28 days) trial period (Payment by Results, PbR), and 50% reimbursed with the cost of 6 weeks (42 days) treatment for other patients discontinuing (Cost Sharing, CS). The aim of our study was to describe the Sativex discontinuation profile from a large population of spasticity treated Italian MS patients.

          Methods

          We collected data of patients from 30 MS centres across the country starting Sativex between January 2014 and February 2015. Data were collected from the mandatory Italian Medicines Agency (AIFA) web-registry. Predictors of treatment discontinuation were assessed using a multivariate Cox proportional regression analysis.

          Results

          During the observation period 631 out of 1597 (39.5%) patients discontinued Sativex. The Kaplan-Meier estimates curve showed that 333 patients (20.8%) discontinued treatment at 4 weeks while 422 patients (26.4%) discontinued at 6 weeks. We found after adjusted modeling that a higher NRS score at T1 (adjHR 2.23, 95% 2.07–2.41, p<0.001) and a lower baseline NRS score (adjHR 0.51 95% CI 0.46–0.56, p<0.001) were predictive of treatment discontinuation.

          Conclusion

          These data show that the first 6 weeks are useful in identifying those patients in which Sativex could be effective, thus avoiding the cost of longer term evaluation.

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          Most cited references15

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          Randomized controlled trial of cannabis-based medicine in spasticity caused by multiple sclerosis.

          Symptoms relating to spasticity are common in multiple sclerosis (MS) and can be difficult to treat. We have investigated the efficacy, safety and tolerability of a standardized oromucosal whole plant cannabis-based medicine (CBM) containing delta-9 tetrahydrocannabinol (THC) and cannabidiol (CBD), upon spasticity in MS. A total of 189 subjects with definite MS and spasticity were randomized to receive daily doses of active preparation (n = 124) or placebo (n = 65) in a double blind study over 6 weeks. The primary endpoint was the change in a daily subject-recorded Numerical Rating Scale of spasticity. Secondary endpoints included a measure of spasticity (Ashworth Score) and a subjective measure of spasm. The primary efficacy analysis on the intention to treat (ITT) population (n = 184) showed the active preparation to be significantly superior (P = 0.048). Secondary efficacy measures were all in favour of active preparation but did not achieve statistical significance. The responder analysis favoured active preparation, 40% of subjects achieved >30% benefit (P = 0.014). Eight withdrawals were attributed to adverse events (AEs); six were on active preparation and two on placebo. We conclude that this CBM may represent a useful new agent for treatment of the symptomatic relief of spasticity in MS.
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            A double-blind, randomized, placebo-controlled, parallel-group study of Sativex, in subjects with symptoms of spasticity due to multiple sclerosis.

            Muscle spasticity is common in multiple sclerosis (MS), occurring in more than 60% of patients. To compare Sativex with placebo in relieving symptoms of spasticity due to MS. A 15-week, multicenter, double-blind, randomized, placebo-controlled, parallel-group study in 337 subjects with MS spasticity not fully relieved with current anti-spasticity therapy. The primary endpoint was a spasticity 0-10 numeric rating scale (NRS). Intention-to-treat (ITT) analysis showed a non-significant improvement in NRS score, in favor of Sativex. The per protocol (PP) population (79% of subjects) change in NRS score and responder analyses (> or =30% improvement from baseline) were both significantly superior for Sativex, compared with placebo: -1.3 versus -0.8 points (change from baseline, p=0.035); and 36% versus 24% (responders, p=0.040). These were supported by the time to response (ITT: p=0.068; PP: p=0.025) analyses, carer global impression of change assessment (p=0.013) and timed 10-meter walk (p=0.042). Among the subjects who achieved a > or =30% response in spasticity with Sativex, 98, 94 and 73% reported improvements of 10, 20 and 30%, respectively, at least once during the first 4 weeks of treatment. Sativex was generally well tolerated, with most adverse events reported being mild-to-moderate in severity. The 0-10 NRS and responder PP analyses demonstrated that Sativex treatment resulted in a significant reduction in treatment-resistant spasticity, in subjects with advanced MS and severe spasticity. The response observed within the first 4 weeks of treatment appears to be a useful aid to prediction of responder/non-responder status.
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              Performance-based risk-sharing arrangements-good practices for design, implementation, and evaluation: report of the ISPOR good practices for performance-based risk-sharing arrangements task force.

              There is a significant and growing interest among both payers and producers of medical products for agreements that involve a "pay-for-performance" or "risk-sharing" element. These payment schemes-called "performance-based risk-sharing arrangements" (PBRSAs)-involve a plan by which the performance of the product is tracked in a defined patient population over a specified period of time and the amount or level of reimbursement is based on the health and cost outcomes achieved. There has always been considerable uncertainty at product launch about the ultimate real-world clinical and economic performance of new products, but this appears to have increased in recent years. PBRSAs represent one mechanism for reducing this uncertainty through greater investment in evidence collection while a technology is used within a health care system. The objective of this Task Force report was to set out the standards that should be applied to "good practices"-both research and operational-in the use of a PBRSA, encompassing questions around the desirability, design, implementation, and evaluation of such an arrangement. This report provides practical recommendations for the development and application of state-of-the-art methods to be used when considering, using, or reviewing PBRSAs. Key findings and recommendations include the following. Additional evidence collection is costly, and there are numerous barriers to establishing viable and cost-effective PBRSAs: negotiation, monitoring, and evaluation costs can be substantial. For good research practice in PBRSAs, it is critical to match the appropriate study and research design to the uncertainties being addressed. Good governance processes are also essential. The information generated as part of PBRSAs has public good aspects, bringing ethical and professional obligations, which need to be considered from a policy perspective. The societal desirability of a particular PBRSA is fundamentally an issue as to whether the cost of additional data collection is justified by the benefits of improved resource allocation decisions afforded by the additional evidence generated and the accompanying reduction in uncertainty. The ex post evaluation of a PBRSA should, however, be a multidimensional exercise that assesses many aspects, including not only the impact on long-term cost-effectiveness and whether appropriate evidence was generated but also process indicators, such as whether and how the evidence was used in coverage or reimbursement decisions, whether budget and time were appropriate, and whether the governance arrangements worked well. There is an important gap in the literature of structured ex post evaluation of PBRSAs. As an innovation in and of themselves, PBRSAs should also be evaluated from a long-run societal perspective in terms of their impact on dynamic efficiency (eliciting the optimal amount of innovation). Copyright © 2013 International Society for Pharmacoeconomics and Outcomes Research (ISPOR). Published by Elsevier Inc. All rights reserved.
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                Author and article information

                Contributors
                Role: ConceptualizationRole: Data curationRole: Formal analysisRole: Writing – original draftRole: Writing – review & editing
                Role: ConceptualizationRole: Data curationRole: InvestigationRole: Writing – review & editing
                Role: Formal analysisRole: InvestigationRole: Writing – review & editing
                Role: Formal analysisRole: InvestigationRole: Writing – review & editing
                Role: Formal analysisRole: InvestigationRole: Writing – review & editing
                Role: Formal analysisRole: InvestigationRole: Writing – review & editing
                Role: Formal analysisRole: InvestigationRole: Writing – review & editing
                Role: Formal analysisRole: InvestigationRole: Writing – review & editing
                Role: Formal analysisRole: InvestigationRole: Writing – review & editing
                Role: Formal analysisRole: InvestigationRole: Writing – review & editing
                Role: Formal analysisRole: InvestigationRole: Writing – review & editing
                Role: Formal analysisRole: InvestigationRole: Writing – review & editing
                Role: Formal analysisRole: InvestigationRole: Writing – review & editing
                Role: Formal analysisRole: InvestigationRole: Writing – review & editing
                Role: Formal analysisRole: InvestigationRole: Writing – review & editing
                Role: Formal analysisRole: InvestigationRole: Writing – review & editing
                Role: Formal analysisRole: InvestigationRole: Writing – review & editing
                Role: Formal analysisRole: InvestigationRole: Writing – review & editing
                Role: Formal analysisRole: InvestigationRole: Writing – review & editing
                Role: Formal analysisRole: InvestigationRole: Writing – review & editing
                Role: Formal analysisRole: InvestigationRole: Writing – review & editing
                Role: Formal analysisRole: InvestigationRole: Writing – review & editing
                Role: Formal analysisRole: InvestigationRole: Writing – review & editing
                Role: Formal analysisRole: InvestigationRole: Writing – review & editing
                Role: Formal analysisRole: InvestigationRole: Writing – review & editing
                Role: Formal analysisRole: InvestigationRole: Writing – review & editing
                Role: Formal analysisRole: InvestigationRole: Writing – review & editing
                Role: Formal analysisRole: InvestigationRole: Writing – review & editing
                Role: Formal analysisRole: InvestigationRole: Writing – review & editing
                Role: Formal analysisRole: InvestigationRole: Writing – review & editing
                Role: InvestigationRole: ValidationRole: Writing – review & editing
                Role: ConceptualizationRole: Data curationRole: InvestigationRole: Project administrationRole: ValidationRole: Writing – original draftRole: Writing – review & editing
                Role: Editor
                Journal
                PLoS One
                PLoS ONE
                plos
                plosone
                PLoS ONE
                Public Library of Science (San Francisco, CA USA )
                1932-6203
                1 August 2017
                2017
                : 12
                : 8
                : e0180651
                Affiliations
                [1 ] Department of Medical, Surgical Science and Advanced Technology "GF Ingrassia"–University of Catania, Catania, Italy
                [2 ] Neurology Unit, Department Head And Neck, ASL3 Genova, Italy
                [3 ] Department NEUROFARBA—University of Florence, Florence, Italy
                [4 ] Department of Neurology—Neurology Institute C Mondino, Pavia, Italy
                [5 ] I clinic Neurology—II University of Naples, Naples, Italy
                [6 ] Neurology Operating Unit and Multiple Sclerosis Center—Provincial Health Authority of Cosenza, Cosenza, Italy
                [7 ] Multiple Sclerosis Centre—University Federico II, Naples, Italy
                [8 ] Demyelinating Diseases Centre—Foggia Hospital, Foggia, Italy
                [9 ] A.O.U: Cittàdella Salute e dellaScienza di Torino, Torino, Italy
                [10 ] Neuroscience Department—University Tor Vegata, Rome, Italy
                [11 ] Unit of Neurology and of Neurorehabilitation, IRCCS Neuromed, Pozzilli (IS), Italy
                [12 ] Department of Neurology–San Raffaele Hospital, Milan, Italy
                [13 ] Neuroimmunology Unit—Villa Sofia-Cervello Hospital, Palermo, Italy
                [14 ] Neurology Clinic—Ancona Hospital, Ancona, Italy
                [15 ] Multiple Sclerosis Center, Dept. Neurol. Psich—Sapienza University, Rome, Italy
                [16 ] Department of Neuroscience, Biomedicine and Movement Multiple Sclerosis Centre–University of Verona, Verona, Italy
                [17 ] Neurology Division—San Camillo Hospital, Rome, Italy
                [18 ] Multiple Sclerosis Centre—Sant'Antonio Abate Hospital, Gallarate, Italy
                [19 ] Multiple Sclerosis Centre—University Hospital Pisa, Pisa, Italy
                [20 ] Multiple Sclerosis Center—Second University of Naples, Naples, Italy
                [21 ] Multiple Sclerosis Centre—Cardarelli Hospital, Naples, Italy
                [22 ] Department of Medical Sciences—University of Cagliari, Cagliari, Italy
                [23 ] Multiple Sclerosis Centre (CRESM)—San Luigi Gonzaga Hospital, Orbassano, Italy
                [24 ] Multiple Sclerosis Centre—Cattolica University, Rome, Italy
                [25 ] Multiple Sclerosis Centre—Vaio Hospital, Fidenza, Italy
                [26 ] Multiple Sclerosis Centre—S. Andrea Hospital, Rome, Italy
                [27 ] Multiple Sclerosis Centre—IRCCS Don Gnocchi Foundation, Milan, Italy
                [28 ] Multiple Sclerosis Centre—IRCCS-Bonino Pulejo Centre, Messina, Italy
                [29 ] Multiple Sclerosis Centre—San G. Moscati Hospital, Avellino, Italy
                [30 ] Department of Basic Medical Sciences, Neuroscience and Sense Organs—University of Bari “Aldo Moro” Bari, Italy
                [31 ] Department of Medical Sciences, Institute of Neurology—University “Magna Graecia”, Catanzaro, Italy
                Heinrich-Heine-Universitat Dusseldorf, GERMANY
                Author notes

                Competing Interests: Dr Messina has received honoraria for scientific lectures form Biogen, Almirall, travel payment from Novartis, Biogen Idec, Genzyme, Almirall Bayer Schering, Merck Serono, Teva, and she serves on a scientific advisory board for Biogen. Dr Solaro received honoraria from Biogen, Genzyme, Novartis, Merck Serono, Almirall, Teva. Dr Righini has nothing to disclose. Dr Bergamaschi has received honoraria for scientific lectures and travel payment from Biogen, Novartis, Teva, Genzyme, Bayer Schering, Merck Serono, Almirall. Prof Bonavita received speaker and advisory board honoraria from Biogen, Novartis and Merck-Serono. Dr Bruno Bossio received a grant for advisory board activities from Almirall. Dr Brescia Morra has received honoraria for scientific lectures and travel payment from Biogen, Novartis, Teva, Genzyme, Bayer Schering, Merck Serono, Almirall. Dr Costantino reveived honoraria for speaking activities from Genzyme, Merck-Serono, Biogen and Novartis. Dr Cavalla has nothing to disclose. Prof DiegoCentonze is an Advisory Board member of Almirall, Bayer Schering, Biogen, Genzyme, GW Pharmaceuticals, Merck-Serono, Novartis, Teva and received honoraria for speaking or consultation fees from Almirall, Bayer Schering, Biogen Idec, Genzyme, GW Pharmaceuticals, Merck Serono, Novartis, Sanofi-Aventis, Teva. He is also an external expert consultant of the European Medicine Agency (EMA), and the principal investigator in clinical trials for Bayer Schering, Biogen Idec, Merck Serono, Mitsubishi, Novartis, Roche, Sanofi-aventis, Teva. His preclinical and clinical research was supported by grants from Bayer, Biogen, MerckSerono, Novartis e Teva. Prof Comi has received honoraria for scientific lectures from Biogen, Novartis, Teva, Genzyme, Bayer Schering, Merck Serono, Almirall. Dr Cottone has received honoraria for advisory board activity from Bayer Schering. Prof Danni has received honoraria for scientific lectures from Novartis, Merck-Serono, Biogen, Teva. Dr Francia received a grant for advisory board activities from Almirall. Dr Gajofatto has received support for travel to scientific meetings from Almirall, Biogen, Genzyme, Merck-Serono and Novartis. Dr Gasperini received honoraria from Biogen, Genzyme, Novartis, Merck Serono, Almirall, Teva. Dr Zaffaroni received honoraria from Biogen, Genzyme, Novartis, Merck Serono, Almirall, Teva. Dr Petrucci has nothing to disclose. Dr Signoriello has nothing to disclose. Dr Maniscalco received speaking and advisory honoraria from Biogen, Novartis and Teva. Dr Spinicci has nothing to disclose. Dr. Matta received honoraria for serving in the scientific advisory boards of Almirall, Novartis, Biogen, Genzyme. Dr Mirabella received honoraria from Biogen, Genzyme, Novartis, Merck Serono, Almirall, Teva. Dr Pedà has nothing to disclose. Dr Castelli has nothing to disclose. Dr Rovaris received honoraria from Biogen, Genzyme, Novartis, Merck Serono, Almirall, Teva. Dr Sessa received honoraria from Biogen, Genzyme, Novartis, Merck Serono, Almirall, Teva. Dr Spitaleri has nothing to disclose. Dr Paolicelli has nothing to disclose. Dr Granata has nothing to disclose. Prof Zappia has received compensation for consulting services from Boehringer-Ingelheim, Lundbeck, Union ChimiqueBelge and scientific grants from AIFA-AgenziaItaliana del Farmaco, Novartis, Lundbeck. Prof Patti has received honoraria for scientific lectures and travel payment from Biogen, Novartis, Teva, Genzyme, Bayer Schering, Merck Serono, Almirall. This does not alter our adherence to PLOS ONE policies on sharing data and materials.

                ¶ The complete membership of the author group can be found in the Acknowledgments.

                Author information
                http://orcid.org/0000-0002-6923-0846
                Article
                PONE-D-17-04806
                10.1371/journal.pone.0180651
                5538735
                28763462
                901ef5c9-9c60-4760-b345-967ead77f11d
                © 2017 Messina et al

                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                : 6 February 2017
                : 19 June 2017
                Page count
                Figures: 2, Tables: 2, Pages: 10
                Funding
                The authors received no specific funding for this work.
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