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A randomized, double-blind, placebo-controlled MRI study of anti–herpes virus therapy in MS

From the Department of Neurology (Drs. Bech, Gadeberg, Hansen, and Jakobsen) and the Center for Nuclear Magnetic Resonance (Dr. Christensen), Aarhus University Hospital; Institute of Medical Microbiology and Immunology (Drs. Haahr and Höllsberg), Aarhus University, Denmark; Department of Neurology (Drs. Lycke, Malmeström, and Andersen) and MRI Center at Sahlgrenska University Hospital (Dr. Ekholm), Gothenburg; and the Institute of Microbiology (Drs. Bergström and Svennerholm), University of Gothenburg, Sweden.

Address correspondence and reprint requests to Dr. Johannes Jakobsen, Department of Neurology, Aarhus University Hospital, Norrebrogade 44, DK-8000 Aarhus C, Denmark; e-mail: Bechprivat{at}dadlnet.dk

Objective: To evaluate the effect of treatment with the antiherpes drug valacyclovir on MRI-evident lesions in patients with relapsing-remitting MS in a phase 2, randomized, double-blind, placebo-controlled study.

Background: It has been postulated from virologic studies that herpesvirus infection could play a role in the progression of MS.

Methods: Patients were eligible for the study if they had had two or more MS relapses in the 2-year period before enrollment. Seventy patients with Expanded Disability Status Scale scores of 0 to 5.5 were randomly assigned to receive 1 gram of valacyclovir (n = 36) or placebo (n = 34) three times daily for 24 weeks. Patients underwent MRI every fourth week for 32 weeks: twice during pretreatment, six times during treatment, and once after treatment. Scoring of neurologic disability was performed at the start and end of the treatment period. The primary endpoint was the number of new active MRI-evident lesions over 24 weeks of treatment. Secondary endpoints included other MRI measures and clinical endpoints.

Results: The mean number of new active lesions ± SD per patient during 24 weeks of treatment with valacyclovir was 11.9 ± 17.6 and that during placebo treatment was 14.5 ± 21.4. A protocol-planned exploratory analysis stratified patients according to baseline activity; this analysis showed that patients with high levels of disease activity in the valacyclovir treatment group (n = 17) developed fewer new active lesions per scan than did those in the placebo treatment group (n = 11). The median number (Q₁, Q₃ range) of active lesions was 2.0 (1.38, 3.96) in the valacyclovir treatment group and 6.5 (2.63, 9.0) in the placebo treatment group.

Conclusions: Valacyclovir treatment did not reduce the formation of active lesions in patients with relapsing-remitting MS who had two or more relapses during the previous 2-year period. In a subgroup of patients with high levels of disease activity who had more than one active MRI-evident lesion during 4 weeks, valacyclovir treatment was associated with a reduced number of new active MRI-evident lesions and with an increase in the number of scans free of new active lesions. The results of the exploratory subgroup analysis provide support for further studies of antiherpes therapy for patients with MS and high levels of MRI-evident disease activity.

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