AAN 2017: Is switching treatments effective?
American Academy of Neurology annual meeting, Boston MA, 22-28 April 2017
Many treatments are now available to treat multiple sclerosis. This raises two important questions: is the drug you’re taking your best option; and what do I take if it isn’t?
The drug you are taking to control your MS may be fine if you can tolerate it, and if it seems to be working. But feeling better on a treatment isn’t necessarily the best gauge. You can feel well despite active disease. So regular visits every 6-12 months to a neurologist, and annual MRIs, are needed to ensure that your medication is doing its job.
The most common reason for switching treatments is if you can’t cope with a given drug’s side effects. The advent of oral therapies (e.g. Aubagio and Tecfidera) has led to many people switching off their injectable medication (one of the interferons or Copaxone). Also common is a switch because a drug isn’t effective enough to control the person’s MS. In this scenario, many people switch to a more potent oral medication (Gilenya), or one of the infusion drugs (Tysabri, Lemtrada and Ocrevus), to try to get their MS under control.
Are these switches effective? And will I be better off?
Several studies presented at AAN 2017 addressed this question in different ways. Here is what the researchers found about various switches:
Are people more satisfied when they switch to Aubagio? The TERI-PRO study looked at people’s satisfaction with treatment during a 48-week trial of Aubagio (Coyle and colleagues. AAN 2017; abstract P3.353). Satisfaction was compared to when they were on a previous medication. Aubagio scored higher than injectables and Tecfidera in satisfaction ratings, suggesting that people felt it was a good move to go from an injectable/Tecfidera to Aubagio.
What treatment will I be able to keep taking? U.S. researchers looked to a large pharmacy database of people switching off an injectable to see which treatments people found more acceptable, as shown by their prescription renewals (Korn and colleagues. AAN 2017; abstract P2.397). Over the 3-year period, about 2,200 people switched off an interferon, and about 1,400 stopped Copaxone. Switchers were more likely to stay with Gilenya over the long haul. The persistence rate was somewhat lower with Aubagio and Tecfidera. People switching from one injectable to another (either an interferon to Copaxone, or vice-versa) had the hardest time staying with the program.
What do I do after Tysabri? Tysabri is a highly effective medication, but its use is generally limited to two years because of the increasing risk of PML (progressive multifocal leukoencephalopathy), a potentially fatal brain infection. This creates a difficult situation: Tysabri is typically started in people with active disease. When it’s time to stop, another medication may not be able to minimize the flare-up that commonly occurs after switching off Tysabri.
Two studies have examined this issue. The first study used information from the Tysabri Observational Program (TOP), a database of Tysabri patients (Trojano and colleagues. AAN 2017; abstract P2.399). The data showed that most people (58%) switched to Gilenya, and about 10% switched either to Tecfidera, an interferon, or Copaxone. After switching, there was an increased risk of a relapse. However, relapses were not as frequent as before the start of treatment (i.e. before Tysabri was started). People were less likely to show improvement in their disability after switching to another drug, but 17% did show some improvement, suggesting that there are effective options once it’s time to stop Tysabri.
TOP didn’t include anyone switching from Tysabri to Lemtrada – perhaps the most potent MS medication. But a small study of 8 people did look at this (Bertolotto and colleagues. AAN 2017; abstract P2.407). All subjects stopped Tysabri because of concerns about PML. An MRI six months after switching to Lemtrada showed no disease activity in the brain, and no one had a relapse or worsening disability after making the switch. These results are very preliminary, but suggest that people may be able to transition from Tysabri to Lemtrada. However, caution will be needed to ensure that the person stopping Tysabri doesn’t already have PML before they start Lemtrada (the consequences of this aren’t known because no one has developed PML on Lemtrada). Frequent MRIs would be needed while the person is taking Tysabri, after they’ve stopped Tysabri and before they’ve started Lemtrada, and while on Lemtrada.
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