Helen Tremlett

Few population-based, methodologically rigorous studies have evaluated the association between mental health and health behaviours in MS. The goal of this dissertation is to contribute to the broader understanding of these relationships and their potential impact on MS. This dissertation was based on two main cohorts: 1) a multi-site clinic-based longitudinal cohort from across Canada; 2) a population-based health administrative and clinical cohort in British Columbia. A large (n=949) sample of MS patients were recruited from four Canadian MS clinics. Participants completed a series of questionnaires at three visits over two years. The prevalence of psychiatric comorbidities (depression [35%] and anxiety [54%]), and adverse health behaviours (smoking [24%] and non-adherence to disease-modifying therapies (DMTs) [22%]) was high. Alcohol dependence was associated with increased odds of anxiety (Odds Ratio (OR):1.84;95% confidence interval (CI):1.32–2.58) and depression (OR:1.53;95%CI:1.05–2.23), as was smoking (anxiety OR:1.29;95% CI:1.02–1.63; depression OR:1.37;95%CI:1.04–1.78). Non-adherence (
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Drug-induced liver injury is a common cause of acute liver failure; it is also the leading reason for a drug’s withdrawal from the market. Interferon-beta (IFN-β) is a commonly used disease-modifying drug for multiple sclerosis (MS) and is generally safe. However, 30-60% of IFN-β exposed patients experience liver aminotransferase elevations, with an unknown proportion experiencing more severe, medically significant elevations. To date, there are no means of predicting who will experience this adverse drug reaction (ADR), although the application of pharmacogenomics could assist with identifying predictive genomic factors. The purpose of this dissertation was to identify predictive factors associated with IFN-β induced liver injury to mitigate toxicity.The research in this dissertation commenced with a review article summarizing the potential application of pharmacogenomics to severe ADRs in MS and a case report of a patient experiencing a hepatic autoimmune-like complication of IFN-β therapy. An original research article followed; utilizing 942 IFN-β exposed MS patients, primarily from Canada. This population-based study examined the rate of liver injury due to IFN-β in MS patients. Approximately 1 in 50 (or 1.9%) IFN-β exposed patients’ experienced liver injury.A pharmacogenomic case-control study followed, involving 182 patients and a genome-wide scan of 785,230 genomic variants, to identify predictors of IFN-β induced liver injury. A genetic variant within synaptotagmin-14 was strongly associated with the ADR (odds ratio 9.83, 95% confidence interval 4.01-24.10, P-value 9.39 x 10-9) and was specific for liver injury from IFN-β and has been previously correlated with hepatic expression of interferon regulatory factor 6. This represents the first genome-wide association study of an ADR from an MS drug and of drug induced liver injury due to a biological therapy.The clinical, demographic and genomic characteristics identified here could modify the risk of experiencing a clinically significant ADR that often results in the cessation of a potentially useful treatment. Predictive characteristics of those at an increased risk will direct preventative strategies, such as enhanced monitoring for early signs of toxicity or alternative treatment regimens. This dissertation contributes towards the personalization of MS therapy and to the broader pharmacogenomic literature on biological therapies.

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Multiple sclerosis (MS) is a putative autoimmune disease of the central nervoussystem, affecting many adults of childbearing age. Although extensive research hasexamined the association between MS and traditional perinatal outcomes (i.e. cesareansection, birth weight and preterm birth), other important outcomes are understudied,partly due to existing methodological challenges. Using comprehensive populationbaseddatabases including the British Columbia (BC) MS Database, BC PerinatalDatabase Registry, Vital Statistics Birth Registry, Population Data BC Consolidation Fileand Census GeoData, this dissertation investigated the association between MS (andrelated clinical factors) with: labour induction and augmentation; obstetrical epidural andspinal anesthesia; length of birth hospitalization in mothers and their newborns; as wellas birth outcomes in fathers with MS. Overall, individuals with MS were not at increasedrisk for the investigated outcomes compared to the general population with theexception that multiparous women with MS had higher rates of epidural anesthesiacompared to multiparous women in the general population. Within MS women, thosewith longer disease duration had less epidural anesthesia and those with greaterdisability had more labor induction. Men with greater MS disability tended to fatheroffspring with lower mean birth weight, but their newborns were still within the normalrange for the general population.Individuals with MS who wish to have children must also decide betweeninitiating disease-modifying drug (DMD) early to minimize relapses (i.e. MS attacks) ordelaying/stopping therapy prior to conception to avoid potential fetal harm from in uteroDMD exposure. This dissertation explored perinatal outcomes in women and men with iiiMS exposed to DMDs and includes a systematic review of DMD exposure on perinatal outcomes. Data from BC suggest that DMD exposure in men and women with MS does not increase the risk of unfavorable perinatal outcomes. However, best evidence from the systematic review indicates that interferon-beta exposure in women with MS is associated with preterm birth, lower mean birth weight and shorter mean birth length in newborns; nonetheless, growth parameters of exposed newborns remained within normal values for the general population and preterm births tended to be close to term.

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