Getting the most from multiple sclerosis treatment
New recommendations indicate when it’s time to change your MS medication
Multiple sclerosis is a very individual disease with people experiencing various symptoms and different rates of progression. Response to a given multiple sclerosis medication also differs from one person to the next. So the Canadian MS Working Group has published a revised set of recommendations to guide neurologists on how to select the best treatment for people with relapsing-remitting MS (Freedman and colleagues. Can J Neurol Sci 2013;40:307-323). The current recommendations update ones published by the group in 2004 (Freedman and colleagues. Can J Neurol Sci 2004;31:157-168).
In assessing if a person is responding to treatment, physicians are advised to focus on three key areas: relapses, EDSS (which assesses disability), and MRI. For relapses, what’s important is how frequent they are, how severe, and how quickly a person recovers from them. A good indication that a given treatment isn’t effective enough is if a person has more than one relapse per year, a relapse is severe enough that a course of steroids is needed, or if there is lingering disability six months after an attack. Any of these would indicate a High level of concern and a change in therapy should be considered.
The EDSS (Expanded Disability Status Scale) can also be used. A different treatment should also be considered if a person worsens by two EDSS points over the course of a year. For example, a person may have some tingling in the hands and mild visual problems (an EDSS score of 1.5). If this worsened to a score of 3.5 (e.g. some loss of touch sensation and some loss of vision) during the year, a change in treatment may be needed.
The third indicator of treatment response is MRI. If a person develops three or more new lesions during a year on treatment, this indicates inadequate disease control and another therapy should be considered.
These three areas of assessment – relapses, progression and MRI – can also be viewed together. A lesser degree of concern in two or three of these measures would also be a reason to change treatments. For example, if a person has just one relapse during the first year of treatment and two new lesions on their MRI, it’s a good indication that their current therapy isn’t the best option for them.
The recommendations enable doctors to react more quickly and more aggressively if they see any signs of trouble. This is important because the first five years after diagnosis appear to be when MS treatments have their greatest impact. Once multiple sclerosis has run its course for five years, it’s unclear how effective treatments are in preventing disability down the road.
When switching from one treatment to another, the approach will differ depending on the person. If the person appears to have less aggressive disease, an option may be to switch from one injectable to another (e.g. from Copaxone to an interferon, or vice versa). For more active or aggressive disease, it may be advisable to switch to a more potent medication (e.g. from an interferon to Gilenya or Tysabri) to get things under control. The recommendations were developed before Tecfidera became available (Aubagio is not approved in Canada yet), so how these new oral drugs can best be used were not fully addressed. It may be assumed that for someone who doesn’t respond adequately to first-line Tecfidera or Aubagio, the best approach may be to start Gilenya or Tysabri rather than switch to a less effective injectable.
The Canadian recommendations also advise that people take vitamin D supplements. While there is limited evidence that vitamin D reduces the risk of disability, it may provide some benefit and there is a low risk of side effects with supplementation. The recommended dose is 2000-4000 IU per day.
Click on MS Radio to hear an exclusive interview with lead author Dr. Mark Freedman from the University of Ottawa about the new MS treatment recommendations.
The full-text article is available free in the Treatment Guidelines section of the MSology Library.
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