Update on drug therapies for MS – Part 1
The largest annual meeting on multiple sclerosis recently concluded and included were a number of interesting studies on MS treatments. This year’s meeting of the European Committee for Treatment and Research in MS (ECTRIMS) was held jointly with the Americas Committee (ACTRIMS) and was staged as a virtual event on September 11-13, 2020.
Few studies this year looked at people treated with injectable medications, such as glatiramer acetate or one of the interferons, in part because most people now start with an oral drug (e.g. Aubagio or Tecfidera). A study of the Italian MS Registry did report that people starting on an oral medication were half as likely to have a relapse and about one-third less likely to stop treatment compared to those taking an injectable drug (D’Amico and colleagues. ECTRIMS 2020; abstract P344). So oral drugs – in addition to be easier to take – appear to be somewhat more effective than the injectables.
In sifting through the new studies, it’s helpful to consider the questions that the researchers were trying to address.
How well do people do over the long term?
People enrolled in clinical trials of Tecfidera have now been on treatment for up to 13 years. According to the most recent analysis, 45% of people on continuous Tecfidera have been relapse-free for up to 10 years. Overall, 86% have maintained their walking ability and 72% have experienced no worsening of their disability over the past decade (Gold and colleagues. ECTRIMS 2020; abstract FC02.05). People taking Tecfidera did not appear to have a higher risk of infections overall compared to the healthy population; 25% developed a urinary tract infection and 19% had an upper respiratory tract infection over the 10-year period. The risk of a malignancy during treatment was similar to what is seen in the general population.
Can treatment improve quality of life?
The Tericare study found that people’s quality of life did improve in the first two years of treatment with teriflunomide (Prieto Gonzalez and colleagues. ECTRIMS 2020; abstract P0349). In the group under study, the level of disability remained stable and 80% didn’t get worse in the first two years. The main effect on quality of life had to do with the psychological impact of MS, with feelings of mild fatigue and depression remaining much the same over time.
Are oral drugs useful in older people?
Many people switch from Aubagio or Tecfidera to a more potent therapy during the course of their illness in an effort to slow worsening disability. However, it isn’t entirely clear if that potency provides any additional benefit once a person is in their fifties or sixties; the concern is that more potent drugs may raise some safety concerns (such as infections) in older people experiencing age-related changes to their immune systems. So some have argued that older people might do well to de-escalate their treatment to a safer option.
Two studies looked at this issue. The first looked at older people (median age 60 years) in the North American MS patient registry (NARCOMS) treated with Tecfidera (Salter and colleagues. ECTRIMS 2020; abstract P0068). Overall, 74% of older individuals on Tecfidera were relapse-free and 86% had not developed secondary-progressive MS, suggesting that their treatment was beneficial. A separate study found that Aubagio significantly reduced the number of brain lesions across different age groups, but this effect wasn’t significant in people older than age 45 (Oh and colleagues. ECTRIMS 2020; abstract P0203).
How do the oral treatment compare?
Few head-to-head studies have compared MS treatments so indirect methods that involve complex statistical methods are used. Three of the more interesting studies compared Tecfidera with Aubagio and Gilenya. The first involved over 700 people in the Swedish MS registry (Spelman and colleagues. ECTRIMS 2020; abstract P0834). The study found that Tecfidera and Aubagio were very similar with respect to reducing relapses or slowing disability. Both improved quality of life. Tecfidera patients were more likely to stop treatment because of side effects, whereas Aubagio patients were more likely to quit because they felt their treatment wasn’t effective.
Another NARCOMS study compared Tecfidera with Gilenya in over 900 people (Fox and colleagues. ECTRIMS 2020; abstract P0021). After five years, a slightly higher proportion of people taking Tecfidera showed no worsening of their disability (68% compared to 63% with Gilenya). A separate study comparing Tecfidera and Gilenya found that the two drugs were similarly effective with respect to their effects on cognition, manual dexterity, walking speed and disability changes, indicating that both treatments are effective in controlling MS (Hersh and colleagues. ECTRIMS 2020; abstract P0142).
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