The results of the present study suggest a Th2/Th1 balance shift in favour of a Th2 cytokine profile on GA-treated patients, while NAT causes a predominant Th1-biased response. This superior anti-inflammatory shift of GA seems to be mainly mediated by raising IL-4 and IL-10 levels which could lead to a down-regulation of Th1 cytokine secretion. Accordingly, the enhancement of circulating IL-4 and IL-10 and the subsequent detrimental effect on IFN-γ and TNF-α seen in GA-treated RRMS patients may play a protective role from inflammatory response that could affect the clinical course of disease in these patients. In this regard, a stabilization of disability score was found in both NAT and GA patients after one year of treatment. The potential clinical implications of immune response in GA-treated patients have been previously assessed [30–32]. Indeed, Valenzuela et al. [31] reported an increased IL-4/IFN-γ ratio to be associated with a favourable clinical outcome in a study of 36 RRMS patients treated with GA. However, the available findings suggesting the potential association between specific cytokine patterns and clinical response to GA were controversial primarily due to the short follow-up period. A recent study with a longer follow-up period of 3 years has demonstrated that IL-2 + IFN-γ/IL-10 + IL-4 ratio was significantly elevated in those patients with RRMS that suffered from relapses and progressing brain atrophy, suggesting that a specific pattern of Th2/Th1 cytokines may predict clinical response to GA therapy [33]. Moreover, this study suggests that the quotient IL-4 + IL-10/IL-2 + IFN-γ could be a promising parameter to identify patients associated with a highly beneficial response to GA therapy. However, although follow-up data over 3 years were available in this study, the sample size was relatively small to draw firm conclusions. Consequently, further studies including larger cohorts of patients will be required to validate that clinical and immune response correlate in patients treated with GA. Additionally, the mechanisms underlying the relation between cytokine response and clinical outcome in GA treated patients remain as a matter of debate.

The results of the present study show that patients treated with NAT exhibit higher levels of circulating proinflammatory cytokines and chemokines than those treated with GA. These findings are in agreement with previous studies where NAT treatment has been associated with an increased expression of proinflammatory cytokines in peripheral blood mononuclear cells [34, 35]. Accordingly, an increase in activated leukocytes producing proinflammatory cytokines has been found in peripheral blood of NAT-treated patients [34, 36]. Although it is not clear, these findings could probably be due to the inhibition of transmigration of lymphocytes into CNS, resulting in sequestration of activated T cells in the peripheral circulation [36]. The prolonged T-cell activation could result in decreased local immunosurveillance, reactivation of latent viral infections or opportunistic CNS infections, as evidenced by the rare but severe occurrence of progressive multifocal leukoencephalopathy caused by JC virus in NAT-treated patients [37]. Recent evidence has suggested that NAT seem to exert its beneficial effect without affecting regulatory T cell function [28]. Interestingly, NAT therapy has been associated with an increase in some pro-inflammatory and anti-inflammatory cytokines within the first 2 months of therapy, whereas relevant cytokines for MS such as IL-2, IL-7, or IL-1β have been found to be increased after one year of treatment, suggesting different immunological mechanisms [28]. The changes in the Th1/Th2 paradigm do not appear to be applicable to explain the beneficial effect of NAT. The increase of circulating Th1 cytokines could be related to a “rebound” effect that led to the development of new and enlarging T2 lesions previously seen in cohorts of patients discontinuing NAT due to safety issues related to this therapy, particularly regarding PML [38]. This finding has led to the concern that cessation of NAT might promote a worsening of MS disease by increasing inflammatory activity. The most likely explanation is that short exposure to NAT (e.g., 2 infusions) results in blockade of migration and accumulation of activated lymphocytes in the periphery that retain their capacity to cause CNS disease [39].

The main limitations of this study include the small sample size and a one-point measurement of cytokine patterns. However, despite these limitations, our findings are potentially interesting given that to our knowledge, this is the first study to compare the Th1/Th2 bias between GA and NAT treated RRMS patients.