New research addresses key questions about MS meds – ECTRIMS 2018
Highlights from the 34th congress of the European Committee for Treatment and Research in Multiple Sclerosis (ECTRIMS), OCTOBER 10-12, Berlin, Germany – ECTRIMS, the largest MS meeting of the year, showcased about a thousand pieces of new research. While no scientific study can be definitive, each can begin to answer questions that are important to people living with MS. The following is a sampling of what research has reported about some of the MS medications.
When is the best time to start an MS medication? An international group of researchers looked at data for about 12,000 people with MS who had been followed for up to 15 years (Iaffaldano and colleagues. ECTRIMS 2018; abstract 204). During that period, about one-third developed worsening disability. That risk was lowest in people who had started a medication within 6 months of being diagnosed with MS.
Are more potent medications really more effective? The first-generation injectable medications (the interferons and Copaxone) were remarkably safe, but the trade-off was that they were less effective in controlling MS. Newer drugs are more effective but can be associated with some safety concerns. Two studies compared people treated with more effective therapies to see how they fared over time. The first study looked at people who started treatment with an injectable medication for at least two years before switching to Tecfidera or Gilenya and compared them to those who started Tecfidera or Gilenya right away (Lorscheider and colleagues. ECTRIMS 2018; abstract P548). The people starting on an injectable were twice as likely to experience a relapse over the next few years compared to those starting on Tecfidera or Gilenya, suggesting that MS wasn’t being as well controlled with the injectable meds. The second study looked at a database of people treated with a high-efficacy medication early (within 2 years of being diagnosed) or later (more than 4 years after diagnosis) (He and colleagues. ECTRIMS 2018; abstract P919). The high-efficacy drugs of interest were Tysabri, Lemtrada and Ocrevus. In the first 2 years of treatment, the group on the high-efficacy drugs did worse – which reflects that they were put on these medications sooner because they had highly active disease. However, once their disease activity had settled down, the Early group did much better over the longer term. At six years, the Early group showed no change in their level of disability, whereas the Late group were starting to show a slow accumulation of disability.
Do MS medications work in older people? The inflammatory flare-ups that are characteristic of MS tend to become less frequent as people get older. Since MS meds typically target this inflammation, it raises the question of whether treatment is still effective in older people. Two studies examined this issue. An analysis of people treated with Gilenya in various studies compared those who were younger than 30 and those older than 30 years of age (Chitnis and colleagues. ECTRIMS 2018; abstract P601). [The average age of the over-30 group was 44 years.] As expected, younger people had more frequent relapses and less disability. However, Gilenya was as effective in older people, both in terms of reducing relapses and in slowing disability progression. The second study compared people younger and older than age 45 years who were treated in the pivotal trial of Mavenclad (Giovannoni and colleagues. ECTRIMS 2018; abstract P1204). [The median age for the two groups was 35 and 51 years.] The reduction in relapses was about 50% compared to a placebo for both groups. There was also a comparable reduction in MRI lesions in both groups relative to placebo, suggesting that Mavenclad is as effective in people in their forties and fifties as it is in younger people.
Can Tysabri be taken less often? One of the concerns with taking Tysabri is the risk of PML (progressive multifocal leukoencephalopathy), a potentially fatal brain infection. While the likelihood of this is low, the risk increases with cumulative exposure to the drug. One solution that’s been proposed is to reduce the dose. This would lower the cumulative exposure but raises the question of whether Tysabri would still be effective. An Italian study compared how well people did with the usual dose exposure of Tysabri (300 mg given every 4 weeks) and a lower dose exposure (300 mg given every 5-6 weeks) (Clerico and colleagues. ECTRIMS 2018; abstract P587). The two doses had a comparable effect on relapses, suggesting that less frequent dosing is sufficient to control MS. Other studies have reported that this extended-dosing schedule is associated with a lower risk of developing PML (Zhovtis Ryerson and colleagues. ACTRIMS Forum 2018; abstract LB250), although PML can still occur (Scarpazza and colleagues. ECTRIMS 2018; abstract P1247).
Can I take additional course of Lemtrada? The usual dosing of Lemtrada is a week of treatments once a year for two years (5 doses in year 1, 3 doses in year 2). That seems to control MS so well that many people won’t need additional therapy for a while. However, most will require another course after 6-8 years because their disease is becoming more active (Singer and colleagues. ECTRIMS 2018; abstract P913). So if Lemtrada starts to lose its effect, will another course be effective? In the follow-up to the original Lemtrada studies, 44% of people required a third course of treatment (Traboulsee and colleagues. ECTRIMS 2018; abstract P948); most people received the additional therapy a year or two after the usual 2-year course. More treatment appeared to be effective: relapses became less frequent and 88% had no worsening of their disability over the next 3 years.
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