VIEWS & REVIEWS OPEN ACCESS

Serum neurofilament light as a biomarker in

progressive multiple sclerosis
Raju Kapoor, FRCP, Kathryn E. Smith, MS, Mark Allegretta, PhD, Douglas L. Arnold, MD, Correspondence
William Carroll, MBBS, MD, Manuel Comabella, MD, PhD, Roberto Furlan, MD, Christopher Harp, PhD, Dr. Fox
Jens Kuhle, MD, David Leppert, MD, Tatiana Plavina, PhD, Finn Sellebjerg, MD, PhD, Caroline Sincock, PhD, foxr@ccf.org
Charlotte E. Teunissen, PhD, Ilir Topalli, PhD, Florian von Raison, MD, Elizabeth Walker, PhD, and
Robert J. Fox, MD

®
Neurology 2020;95:436-444. doi:10.1212/WNL.0000000000010346

Abstract
There is an unmet need in multiple sclerosis (MS) therapy for treatments to stop progressive
disability. The development of treatments may be accelerated if novel biomarkers are developed
to overcome the limitations of traditional imaging outcomes revealed in early phase trials. In
January 2019, the International Progressive MS Alliance convened a standing expert panel to
consider potential tissue fluid biomarkers in MS in general and in progressive MS specifically.
The panel focused their attention on neurofilament light chain (NfL) in serum or plasma,
examining data from both relapsing and progressive MS. Here, we report the initial conclusions
of the panel and its recommendations for further research. Serum NfL (sNfL) is a plausible
marker of neurodegeneration that can be measured accurately, sensitively, and reproducibly,
but standard procedures for sample processing and analysis should be established. Findings
from relapsing and progressive cohorts concur and indicate that sNfL concentrations correlate
with imaging and disability measures, predict the future course of the disease, and can predict
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response to treatment. Importantly, disease activity from active inflammation (i.e., new T2 and
gadolinium-enhancing lesions) is a large contributor to sNfL, so teasing apart disease activity
from the disease progression that drives insidious disability progression in progressive MS will
be challenging. More data are required on the effects of age and comorbidities, as well as the
relative contributions of inflammatory activity and other disease processes. The International
Progressive MS Alliance is well positioned to advance these initiatives by connecting and
supporting relevant stakeholders in progressive MS.

From the University College London (R.K.), United Kingdom; National Multiple Sclerosis Society (K.E.S., M.A.), New York; McGill University (D.L.A.), Montreal, Canada; Perron Institute
(W.C.), Sir Charles Gairdner Hospital, Perth, Australia; University Hospital Vall d’Hebron (M.C.), Barcelona, Spain; San Raffaele Scientific Institute (R.F.), Milan, Italy; Genentech/Roche
(C.H.), South San Francisco; University Hospital Basel (J.K., D.L.), Switzerland; Biogen (T.P.), Boston; Quanterix Corporation (T.P.), Billerica; Rigshospitalet (F.S.), University of Copen-
hagen, Denmark; Progressive Multiple Sclerosis Alliance (C.S.), Glasgow, United Kingdom; Amsterdam UMC (C.E.T.), the Netherlands; MedDay Pharma (I.T.), Paris, France; Novartis
(F.v.R.), Basel, Switzerland; Elizabeth Walker Consulting (E.W.), Seattle; and Mellen Center for Multiple Sclerosis (R.J.F.), Cleveland Clinic.

Go to Neurology.org/N for full disclosures. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the article.

The Article Processing Charge was funded by the International Progressive MS Alliance.
This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives License 4.0 (CC BY-NC-ND), which permits downloading
and sharing the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.

436 Copyright © 2020 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American Academy of Neurology.
 Glossary
MS = multiple sclerosis; NfL = neurofilament light chain; Simoa = single molecule array; sNfL = serum NfL; T25FW = Timed
25-Foot Walk time; 9HPT = 9-Hole Peg Test time.

Treatment to prevent gradual progression of disability re- concentrations, which avoids the need to sample CSF,9,10 thus
mains a major unmet medical need in multiple sclerosis (MS) offering more convenient testing and increased acceptability
and was a driving force for initiation of the International of sampling by patients. Modeling suggests that NfL as a
Progressive MS Alliance (“the Alliance”) in 2012. The specific biomarker may have comparable sensitivity to imaging out-
mission of the Alliance is to accelerate the development of comes for testing efficacy in phase 2 trials of relapsing MS.11
effective disease-modifying and symptom management ther-
apies for persons with progressive forms of MS.1 Consequently, the Alliance convened an expert panel to
discuss the current state of research on NfL as a biomarker in
The Alliance acknowledges that a central aspect to success of MS in general and progressive MS specifically, with a view to
its mission is to accelerate proof-of-concept clinical trials of mobilizing the MS community toward filling key gaps in
new therapies in progressive MS, thereby encouraging drug knowledge and understanding. Because much of the initial
development2 and stimulating further investment from in- NfL data were collected in relapsing MS and provided im-
dustry. Ideally, early-stage trials depend on treatment re- portant insights regarding its use and relevance in MS, we
sponse biomarkers, which predict clinical benefits and allow have included it here as foundational studies. Here, we
treatment effects to be detected more quickly and with smaller summarize the outcome of the group’s meeting in Wash-
sample sizes than trials using clinical measures as primary ington DC in January 2019 and its subsequent discussions.
outcomes. For relapsing MS, this requirement has been met Based on published regulatory guidance,12 2 potential
by lesion activity on conventional MRI.3 Contexts of Use were agreed upon as the basis for further
work:
Numerous pathologic mechanisms are purported to con-
tribute to the progression of disability in progressive forms of 1. sNfL as a pharmacodynamic/treatment response bio-
MS, but no dominant mechanism has been identified.2
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marker, to be used as an end point/outcome monitor in

Therefore, biomarkers of specific pathologic mechanisms are clinical trials in progressive MS
unlikely to be informative for proof-of-concept trials of ther- 2. sNfL as a prognostic biomarker that can predict disease
apies with varying modes of action. Instead, the focus has been progression, to be used for the selection of patients with
to identify biomarkers of neurodegeneration, which integrates progressive MS into trials
the end-stage consequences of combined pathologies. Sample
size calculations from longitudinal studies have enabled the
adoption of brain atrophy, measured using MRI, as a bio-
marker of progressive MS and used as the primary outcome in
Plausibility and analytical validity
phase 2 trials.4–7 Neurofilaments are plausible biomarkers of neurodegeneration
because they are cytoskeletal proteins confined to the neuro-
Despite its intuitive association with loss of neural tissue, brain axonal compartment.13 Their concentrations are elevated
atrophy has a number of limitations as a treatment response across a wide range of neurologic diseases, consistent with
biomarker. Loss of volume is not pathologically specific, de- release on axonal damage from multiple causes.13 Although the
pends on many factors such as tissue hydration, and thus most widely used monoclonal antibodies for NfL14 have been
follows a complicated trajectory after starting treatment.8 highly specific in NfL knock-out animal experiments,15 the
Thus, additional biomarkers, in particular those related spe- extent to which intact NfL and its degradation products con-
cifically to neuronal structure and function, are required to tribute to the immunoassay signal is unclear. This limits the
monitor progressive MS. interpretation of NfL kinetics in individual patients.

Body fluid biomarkers have the potential to be more patho- Currently, the most widely used assay for measuring serum or
logically specific than imaging biomarkers, may reflect ongo- plasma concentrations of NfL is the Quanterix platform,
ing pathology over the entire CNS, and may be more which uses single molecule array (Simoa) technology and is
responsive to the effects of treatment. Through 2017, the available commercially.16 Technical validation of this assay
Alliance considered a number of biomarkers and decided at its indicates good analytical accuracy. A recent multicenter study
Future Strategies Meeting in Dublin, Ireland, in July 2018 to analyzing identical serum samples across different sites
focus on neurofilament light chain (NfL) as a test candidate. reported excellent interassay and intersite coefficients of
This decision followed recent methodological developments variation (<10%).17 Further work is still required to establish
that allow ultra-sensitive measurements of serum NfL (sNfL) interbatch and within-batch assay variability.18

Neurology.org/N Neurology | Volume 95, Number 10 | September 8, 2020 437

 A correlation between NfL levels in the serum or plasma and Hence, establishing reference values (e.g., a normative data-
levels in the CSF has been demonstrated for various neuro- base) over a wide range of ages and evaluating the effects of
logic diseases and suggests that measures of ongoing neuro- comorbidities (i.e., cerebrovascular disease, diabetes, and
axonal injury can be obtained from blood NfL levels without smoking status) on serum concentrations are critical next steps
the need to obtain CSF by lumbar puncture.13 These results for developing NfL as a tool for personalized medicine in MS,
are consistent with small studies in progressive MS indicating especially for patients with progressive MS.
a modest correlation between NfL concentrations in serum/
plasma and CSF. For example, analysis of the progressive MS For the use of NfL concentration as a biomarker in clinical
patient subset from Disanto et al.19 indicated an r of 0.7 (n = trials, the effects of age and comorbidities can be controlled on
18), although other studies showed a weaker correlation.20 relative grounds by both covariate adjustment and randomi-
Larger studies are needed to better understand the relation- zation, although these confounding variables may limit pre-
ship between blood and CSF levels of NfL. cision, interpretation, and strength of association with
outcomes. Hence, a normative database of NfL is an in-
NfL concentrations are approximately 20% higher when mea- dispensable tool to address this limitation. Such a database
sured in serum compared with plasma, which indicates that would also enable quantitative modeling of disease pro-
serum and plasma levels are not interchangeable within the gression, which has been a valuable tool for parsing relevant
same study. A few studies have assessed the stability of NfL. covariates such as age that significantly influence relevant
There appears to be minimal effect of freezing and thawing on clinical trial outcomes. A normative database could help en-
NfL concentrations,21,22 and sNfL concentrations are stable in able application of NfL measurement to individual patient
samples stored for 1 week at either room temperature or at monitoring and therapeutic decision making. Such models
4°C21 (also Teunissen, unpublished). NfL appears to remain have been developed for other relevant outcome measures,
stable in samples stored under standard biobanking conditions reviewed by regulators, and made available for clinical trial
over many years.19 Despite these encouraging findings, stan- optimization in diseases such as Alzheimer disease,28 Par-
dard protocols are needed to define the acceptable parameters kinson disease,29 and autosomal dominant polycystic kidney
for type of collection tube, delay in processing, and processing disease.30
methods.
Comparisons with imaging and
Apart from Simoa, other high-sensitivity platforms apply disability measures
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similar reagents, such as the Olink proximity ligation protein Numerous retrospective academic cohort studies19,25,31–33
analysis neuropanel. Novel automated systems include the and analyses of large phase 3 trials in relapsing MS24,34 suggest
Cobas Elecsys system by Roche and the ADVIA immunoassay that the concentration of NfL in serum, plasma, and CSF is a
system by Siemens. Although the increasing availability of promising biomarker in MS. Applications include (1) acute
multiple systems is likely to facilitate widespread imple- disease activity (including correlations with baseline T2 lesion
mentation in research and clinical care, reference methods volume and the number of enhancing T1 lesions) and (2)
and materials are needed to ensure data comparability across prediction of subsequent MRI lesion activity, brain volume
different systems. loss, relapse rate, and worsening of disability. In patients with
Alzheimer disease and amyotrophic lateral sclerosis, in-
creasing mean serum concentrations occur months or years
before the emergence of the first clinical manifestations.35,36
Clinical validity Similarly, an increased CSF NfL concentration in radiologi-
NfL is a highly sensitive marker of neuronal injury, irrespective cally isolated syndrome is a risk factor for later transition to
of the cause of that injury. However, NfL concentrations are clinically definite MS.37,38
typically far lower in MS than in many rapidly progressive
primary neurodegenerative diseases, which show a faster rate of Recent results from clinical trials in progressive MS accord with
neuronal loss than MS.23 Average serum or plasma NfL con- those in relapsing-remitting disease (table 1) and suggest that
centrations are higher in relapsing and progressive MS than in the concentration of NfL is associated with concurrent disease
controls,19,24,25 although the concentration ranges in MS activity and long-term disease outcome in all forms of MS. In
overlap with controls to an extent that makes it difficult to placebo-controlled phase 3 trials of fingolimod and siponimod,
define a pathologic cutoff at the individual patient level. This baseline plasma NfL concentrations were higher in patients
problem is further complicated by the fact that blood con- with Gd+ lesions at baseline compared with those without Gd+
centrations of NfL increase by an average 2.2% per year be- lesions.39 In both trials, a high NfL concentration at baseline
tween ages 18 and 70 years in healthy controls.19,23,26 The was associated with greater brain volume loss at 1–2 years and a
reasons for this age-dependent increase are not well un- higher likelihood of confirmed disability worsening. These as-
derstood. The parallel increase in CSF and blood suggests that sociations were independent of treatment assignment or the
it is due mainly to physiologic age-dependent neuronal loss, but presence of contrast-enhancing lesions at baseline. From these
metabolic factors may also contribute, similar to the age- data, it was also estimated that a 1-year placebo-controlled trial
dependent increase of the CSF/serum albumin quotient.27 would require a tentative sample size of 94 participants with

438 Neurology | Volume 95, Number 10 | September 8, 2020 Neurology.org/N

 secondary progressive MS per arm to detect a 20% reduction of

Abbreviations: EDSS = Expanded Disability Status Scale; MS = multiple sclerosis; NfL = neurofilament light chain; RCT = randomized controlled trial; SDMT = Symbol Digit Modalities Test; T25FW = Timed 25-Foot Walk time;
Placebo data only
placebo subjects

placebo subjects
NfL concentration with 80% power.39

treatment and

treatment and
Comments

Combined
Combined
Similarly, in a phase 3 trial of natalizumab, baseline sNfL
concentration was associated with (1) baseline disease activity
and disability measures, including the number of Gd+ lesions,
baseline NfL and clinical

T2 lesion volume, Timed 25-Foot Walk time (T25FW), and

Correlations between

(EXPAND study only53)

9-Hole Peg Test time (9HPT), and (2) brain atrophy over 96

EDSS; T25FW; 9HPT

2. SDMT worsening
1. EDSS worsening

weeks. sNfL concentration at week 96 was also significantly

higher in participants who progressed during the study (de-

Not reported
fined using the Expanded Disability Status Scale, T25FW, or
outcomes

9HPT) compared with those who did not.40

When considered with the results in relapsing-remitting MS,

baseline NfL and imaging

Brain volume loss after 12

these similar and more recent findings in progressive MS

Correlations between

support the prognostic Context of Use for NfL defined ear-

lier.41 However, these findings are at a group level and require
Brain volume loss

deeper analysis of the existing trial data and further longitudinal

Not reported
after 96 wk
and 24 mo
outcomes

studies to interpret NfL concentrations at an individual level

and to build a disease model that might support trial enrich-
ment. These studies should clarify (1) the relative contributions
of neurodegeneration and acute inflammatory activity to lon-
gitudinal changes of clinical disability and NfL; (2) the extent
baseline NfL and baseline

and time course of the NfL trajectory following an acute in-

Correlations between

flammatory event (relapse or MRI lesion activity) because NfL

clinical measures

concentrations are dynamic and are elevated for several months

after acute neurologic events including clinical relapse23,42–44;
T25FW, 9HPT

Not reported

and (3) the threshold level of change in the concentration of

Table 1 Associations between baseline NfL concentrations and activity of progressive MS
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NfL, which equates to a threshold change of disability and,

EDSS

therefore, can be accepted as clinically meaningful.

Responsiveness to treatment
baseline NfL and baseline

Gd+ lesion count; T2 lesion

Results from a number of clinical trials in relapsing MS in-

Correlations between

dicate that serum and plasma NfL concentrations respond

imaging measures

Gd+ lesion count;

T2 lesion volume

Gd+ lesion count

consistently within 3–6 months of the start of anti-

inflammatory therapies, that changes in NfL can be associ-
ated with changes in clinical and imaging outcomes, and that
volume

the response of NfL to higher-efficacy therapies such as

alemtuzumab and fingolimod is larger than the response to
interferon-beta.24,31
phase 3 RCTs (EXPAND
Combined data from

Previously, 2 small studies reported positive treatment effects

on CSF concentrations of NfL in progressive MS (table
and INFORMS)
Study design

Phase 3 RCT

Phase 3 RCT

2).45,46 Lower concentrations were observed after treatment

for 12–24 months with either mitoxantrone or rituximab in
patients with primary progressive MS compared with baseline
and with a small group of age-matched controls (table 2). The
subtype and number

difference was most prominent in those patients with evi-

SPMS (n = 1,452) and

dence of ongoing inflammatory activity.45 Treatment with

Progressive MS

PPMS (n = 378)

PPMS (n = 516)
SPMS (n = 365)

natalizumab for 60 weeks was also associated with lower CSF

9HPT = 9-Hole Peg Test time.
of subjects

NfL concentrations in a single-arm, open-label study in a

progressive cohort.46 Furthermore, changes in CSF NfL
correlated with clinical changes during treatment with nata-
lizumab or monthly methylprednisolone.47,48
INFORMS39
Trial name

ORATORIO
ASCEND40
EXPAND

Recently, the initial analyses of peripheral blood NfL con-

and

centrations were communicated from the phase 3 trials of

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440
Neurology | Volume 95, Number 10 | September 8, 2020

Table 2 Response of neurofilament light concentrations to treatment in progressive MS

Study design
Study MS (treatment Subjects for NfL NfL biofluid
reference phenotype duration) Treatment analysis (assay used) Change in NfL concentration Comments

Axelsson SPMS and Observational Rituximab (n = 5) or 30 SPMS, 5 PPMS, CSF (Uman Mean NFL concentration was 1. NfL concentration was only reduced in either previously
et al.45 PPMS phase 2A, with mitoxantrone (n = and 14 healthy Diagnostics NF- reduced 51%, from 1,780 ng/L to untreated patients or those with enhancing lesions at baseline.
age-matched 30) controls light ELISA)14 870 ng/L (p = 0.007) irrespective of
controls (12–24 MS phenotype or treatment
mo)

2. There was no correlation between NfL concentrations at

different time points and pre- and posttreatment EDSS or MSSS
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Romme SPMS and Phase 2A single- Natalizumab 7 SPMS and 10 CSF (Uman Mean NfL concentration was 1. Changes in NfL concentrations correlated with changes in
Christensen PPMS arm (60 wk) PPMS Diagnostics NF- reduced by 37%, from 657 ng/mL to MTR in NAWM and GM. 2. Combined data from this trial and a
et al.46 light ELISA)14 414 ng/mL (p = 0.03) phase 2A trial of methylprednisolone in SPMS and PPMS54
found a correlation between CSF NfL and changes in the MS
Impact Scale

Ratzer SPMS and Phase 2A single- Methylprednisolone 14 SPMS and 11 CSF (Uman Mean NfL concentration not Treatment-associated changes in EDSS, MSFC, 9HPT, T25FW,
et al.48 PPMS arm (60 wk) PPMS Diagnostics NF- reduced by treatment (baseline 827 MSIS, MTR, and DTI measures
light ELISA)14 pg/mL vs final 434 pg/mL, p = 0.067)

INFORMS PPMS Phase 3 Fingolimod or 170 fingolimod and EDTA plasma NfL levels lower in fingolimod- No significant difference between groups at mo 12
randomized trial placebo 119 placebo (Quanterix treated patients than placebo at mo
(24 mo) Simoa NF-light® 24 (p = 0.0012)
Advantage Kit)19

EXPAND49 SPMS Phase 3 Siponimod or 380 siponimod and EDTA plasma Plasma NfL levels increased by
randomized trial placebo 145 placebo (Quanterix 9.2% with placebo and decreased
(>21 mo) Simoa NF-light® by 5.7% with siponimod (p = 0.0004)
Advantage Kit)19

ASCEND40 SPMS Phase 3 Natalizumab or 379 natalizumab Serum sNfL at wk 48 and 96 was lower in 1. Week 96 sNfL was higher in those with progression on the
randomized trial placebo and 365 placebo (Quanterix natalizumab vs placebo (ratios: multicomponent disability endpoint. 2. Differences in sNfL
(96 wk) Simoa NF-light® 0.84, p < 0.001, and 0.80, p < 0.001, were observed in those with and without Gd+ lesions at
Advantage Kit)19 respectively) baseline, relapses in 2 y before study and on-study
inflammatory activity (Gd+ lesions, new T2 lesions, or relapse).

SPRINT52 SPMS and Phase 2 Ibudilast or placebo Serum: 119 CSF and serum No between-group differences in Concurrent anti-inflammatory therapy was only injectibles or
PPMS randomized trial ibudilast and 120 (Quanterix change in NfL in either serum or none; ongoing focal inflammatory activity may have
(96 wk) placebo. CSF: 30 Simoa NF-light® CSF confounded assessment of ibudilast’s effect on NfL
ibudilast and 28 Advantage Kit)19
placebo

ORATORIO50 PPMS Phase 3 Ocrelizumab or 347 ocrelizumab Serum NfL was 15.7% lower with For patients with BL NfL above 90th percentile of healthy
randomized trial placebo 169 placebo (Quanterix ocrelizumab vs 0.2% lower with controls, a higher proportion decreased into normal range with
(96 wk) Simoa NF-light® placebo (p < 0.001) ocrelizumab (40.4%) vs placebo (16.6%) (p < 0.001)
Advantage Kit)19
Neurology.org/N

Abbreviations: DTI = Diffusion Tensor Imaging; GM = Gray Matter; MS = multiple sclerosis; MSFC = Multiple Sclerosis Functional Composite; MSIS = Multiple Sclerosis Impact Scale; MSSS = Multiple Sclerosis Severity Score; MTR =
Magnetization Transfer Ratio; NAWM = Normal Appearing White Matter; NfL = neurofilament light chain; PPMS = Primary Progressive Multiple Sclerosis; Simoa = single molecule array; sNfL = serum NfL; SPMS = Secondary
Progressive Multiple Sclerosis; T25FW = Timed 25-Foot Walk time; 9HPT = 9-Hole Peg Test time.
 Table 3 Next steps needed to increase understanding of sNfL
Opportunities Potential next steps

Standardize sample collection and assay methods to align results across • Review standard operating procedures currently in use
multiple assay platforms.

• Establish standards for sample collection and storage

• Analyze nonstandard sample collection and storage to understand

tolerance for variance in sample collection and storage

• Compare different assay methods to understand comparability

and commutability54

Establish a normative database of NfL concentrations in healthy volunteers to • Establish key parameters for a normative database
establish the effects of age and comorbidities and then develop disease models
to support trial design and clinical validity.

• Clarify types of data, necessary number of samples, appropriate

control groups, and specific potential confounders

Analyze legacy trial biobanks for NfL to determine the predictive value of NfL, • Conduct a landscape analysis to ensure that all legacy data sets are
how NfL responds to different therapies and clarify its relationship to clinical captured
and imaging outcomes. A particular issue is the relative extent to which
inflammatory activity and underlying disease progression contribute to
changes in the concentration of NfL.

• Check availability of biological samples for further analysis

• Outline statistical analysis plans and harmonize across data sets

Abbreviations: NfL = neurofilament light chain; sNfL = serum NfL.

fingolimod and ocrelizumab in primary progressive MS activity, as may have occurred in the SPRINT-MS trial of
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(INFORMS and ORATORIO, respectively) and of sipo- ibudilast described above.

nimod and natalizumab in secondary progressive MS
(EXPAND and ASCEND, respectively) (table 2).39,40,49,50 Further analyses of clinical trial data sets with particular at-
Treatment was associated with lower NfL concentrations tention to disease activity will help clarify the appropriate use
compared with placebo in all 4 trials. A significant NfL and utility of NfL in clinical trials.
response was apparent with or without the presence of
observed inflammatory activity in both the siponimod and
natalizumab trials, but the effect sizes were smaller in the Limitations of NfL
progressive inactive subgroups.40,49 In the ASCEND and
INFORMS trials, a robust reduction in NfL was observed In addition to the technical challenges mentioned earlier, there
despite an absence of clinical benefit.39,40 Ibudilast, which are several limitations in the application of NfL to individual
appears to act on noninflammatory processes to slow patients with MS and the evaluation of MS therapies. NfL is a
whole-brain atrophy without affecting relapse rate or lesion cytoskeletal protein that can be released as a result of almost
activity,51 has been reported on initial analysis of the any type of brain injury. NfL is not specific to MS, and thus, any
SPRINT-MS phase 2 trial to have no effect on the con- neurologic disease or injury can confound efforts to use NfL to
centration of NfL in either serum or CSF.52 Background characterize MS and response to MS therapies. NfL release can
immune modulating therapy in this trial was only injectable arise from infiltrative inflammation seen in relapsing MS (and
therapies (or none), and ongoing inflammatory activity less frequently in progressive MS), but also the various different
may have obscured the ability to detect an ibudilast-related pathologies associated with progressive MS. This confounding
reduction in NfL. Further studies of NfL using legacy trial may limit the ability of NfL to measure the neurodegenerative
biobanks and ongoing trials will help to clarify the re- aspects of progressive MS and potential impact of putative
lationship of changes in NfL concentrations with disability neuroprotective therapies. Understanding the impact of dif-
measures, including the time course of NfL changes and ferent comorbid conditions such as cerebrovascular disease,
their clinical meaningfulness. Importantly, clinical studies diabetes, and smoking status on serum concentrations is a
indicate that disease activity as measured by clinical re- critical next step in developing NfL as a tool for personalized
lapses and MRI (either gadolinium-enhancing or new T2 medicine in MS, especially for patients with progressive MS.
lesions) is associated with increased NfL. Thus, measure- The utility of NfL monitoring for individual patient manage-
ment of NfL in progressive MS trials that target disease ment is not yet defined and might require integrating more
progression may be confounded by intercurrent disease clinical, biological, and imaging features in the future.

Neurology.org/N Neurology | Volume 95, Number 10 | September 8, 2020 441

 Ongoing studies effects of age and comorbidities, which will allow the
development of disease models to support trial design
There are many ongoing studies that will further characterize and clinical validation.
NfL and understand its relevance to MS in general and in 3. A deeper analysis of legacy clinical trial data sets will help
progressive MS specifically. Many clinical trials that bio- clarify the predictive value of baseline concentrations of
banked serum or plasma samples are analyzing NfL. A US sNfL, define how sNfL responds to different types of
NIH-funded study (1U01NS111678-01A1) funded in 2020 therapies, and clarify the relationship between NfL levels
will evaluate NfL as a prognostic and monitoring biomarker in and clinical and imaging outcomes. A particular issue is
over 5,700 individuals with MS. A study funded by the US the relative extent to which inflammatory activity
National MS Society will evaluate sNfL from the US National including activated microglia and other disease processes
Health and Nutrition Examination Survey of healthy adults to contribute to changes in NfL.
assess the effects of demographics, lifestyle factors, and
comorbidities on sNfL levels and establish demographic-
specific reference ranges of sNfL. A study funded by the Swiss Acknowledgment
National Science Foundation will investigate the relationship Marco Salvetti, Catherine Lubetzki, and Susan Kohlhass
between sNfL and MRI characteristics, treatment response, provided critical review of the manuscript on behalf of the
and quality of life and characterize NfL turnover in the blood. International Progressive MS Alliance. Their contributions
NfL is being studied in other neurologic diseases too. The are appreciated.
Biomarkers Consortium of the Foundation of the NIH aims
to establish whether NfL in blood provides a prognostic Study funding
marker that can accelerate the development of disease- Support for this manuscript was provided by the International
modifying therapeutics in familial frontotemporal dementia. Progressive MS Alliance, which is funded by its society, trust,
foundation, and industry members. See progressivemsalliance.
Other initiatives focus on the standardization of measurements org for additional details.
to prepare for the use of blood biomarkers in both clinical trials
and routine clinical practice. For example, the International Disclosure
Federation of Clinical Chemistry Working Group performs a R. Kapoor, K.E. Smith, M. Allegretta, D.L. Arnold, W. Carroll,
round robin/commutability study of NfL in plasma and serum M. Comabella, R. Furlan, C. Harp, J. Kuhle, and D. Leppert
Downloaded from https://www.neurology.org by University of Medicine and Pharmacy Iasi on 18 January 2024

to study the correlation between the different assays and report no disclosures related to this manuscript. T. Plavina is
identify candidate Reference Materials. Future Certified Ref- currently employed by Quanterix, which is a diagnostic
erence Materials can be used to align measurements across company with patient interests in NfL testing. F. Sellebjerg, C.
analytical platforms. The Standardization of Alzheimer Blood Sincock, C.E. Teunissen, I. Topalli, F. von Raison, E. Walker,
Based Biomarkers Working Group of the Alzheimer Associa- and R.J Fox report no disclosures related to this manuscript.
tion Global Biomarkers Standardization Consortium develops Go to Neurology.org/N for full disclosures.
standard operating procedures for blood collection and pro-
cessing for a broad range of potential markers, including NfL. Publication history
These and other efforts will help further our understanding of Received by Neurology January 2, 2020. Accepted in final form
the role of NfL in identifying new therapies and managing the June 26, 2020.
disease in people living with MS.

Appendix Authors
Conclusions
Author Location Contribution
Our review of existing data suggests that sNfL may provide a
Raju University College Design and
plausible biomarker of progressive MS, addressing some of Kapoor, London, England, United conceptualization of the
the limitations of current imaging biomarkers to accelerate FRCP Kingdom study, drafting the original
manuscript, and revising the
drug development through the proposed Contexts of Use. manuscript for intellectual
However, significant gaps remain in our understanding of NfL content
and must be addressed before NfL can be accepted as a bio-
Kathryn E. National Multiple Revising the manuscript for
marker by the progressive MS community and, potentially, by Smith, MS Sclerosis Society, New intellectual content
regulatory agencies. These gaps include the following: York

Mark National Multiple Revising the manuscript for

1. Sample collection and assay methods should be standardized Allegretta, Sclerosis Society, New intellectual content
PhD York
to align results across current (and future) assay platforms,
which will support analytical validity across the globe. Douglas L. McGill University, Revising the manuscript for
Arnold, MD Montreal, Canada intellectual content
2. A normative database of sNfL concentrations in healthy
volunteers is required. This database should include the

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 10. Kuhle J, Barro C, Andreasson U, et al. Comparison of three analytical platforms for
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Child Neurology: A Case-Based Approach
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444 Neurology | Volume 95, Number 10 | September 8, 2020 Neurology.org/N