Update on oral and injectable therapies for MS
The American Academy of Neurology (AAN) is holding its annual meeting this week in Seattle, providing some new information about the disease-modifying therapies (DMTs) used to treat multiple sclerosis. In this issue we will look at injectable and oral therapies. Next week we will summarize what is new with high-potency medications.
Neurology researchers are still gathering data about the impact of the COVID-19 pandemic on people with MS. Over 500 studies have now looked at how DMTs affect a person’s ability to mount an immune response to COVID vaccination. A combined analysis of over one thousand people has concluded that most MS medications – including the injectables (Copaxone, interferons), Tecfidera, Aubagio, Tysabri and Lemtrada – do not impair the response to COVID vaccines (Gombolay et al. AAN 2022; S5.007). These medications can all be taken just before and after receiving a COVID vaccine or booster shot.
The pandemic raised some concerns about chronic suppression of the immune system with MS treatments, particularly in older people. One solution is “de-escalation” – switching from a more potent drug to a less potent one. The MS centre in Colorado, which uses a lot of Rituxan and Ocrevus, looked at switching 10 people (average age 37 years) off these infusion drugs to oral Tecfidera (Vollmer and colleagues. AAN 2022; P3.003). After starting Tecfidera, one person relapsed, and one person had a new MRI lesion detected. Overall, three people stopped treated after a few months.
A separate analysis looked at 195 people in two studies who had switched from Aubagio to Tecfidera (Giles and colleagues. AAN 2022; P3.005). In the year after switching, people saw a reduction in relapses of 75-80%, which may suggest somewhat better control of MS with Tecfidera.
An Italian registry study examined data for 470 people taking oral DMTs (Tecfidera, Aubagio, Gilenya) over a five-year period (Alessia and colleagues. AAN 2022; P17.003). People taking Gilenya had fewer relapses overall. But the three drugs were very similar in their effectiveness in slowing disability.
Also noteworthy from this year’s AAN annual meeting were the six-year safety results for Tecfidera (Pandey and colleagues. AAN 2022; P7.009). In total, 5,090 people were treated with Tecfidera for an average of 27 months. Relapse rates remained low and measures of fatigue, work productivity and mental health were stable. About 6% had serious side effects, most commonly infections. About 22% stopped treatment because of stomach complaints during the study.
An emerging topic in MS research is RIS (radiologically isolated syndrome). This is when an apparently healthy person has an MRI for some reason (e.g. a migraine, head injury, etc.) and the radiologist detects MS-like lesions. RIS is not MS, but in some cases it may be an early warning that MS will develop over the next 5-10 years. The question – and controversy – is whether these people should be started on treatment. Early use of a medication may prevent tissue damage and disability in those who will later develop MS. However, many people with RIS will not develop MS, so they would be exposed to unnecessary treatment and side effects. A few years ago, the phase IV ARISE trial of Tecfidera in people with RIS was announced (Okuda and colleagues. Neurology 2016;84:P7.207). Joining that is the phase III TERIS study, which will examine the effects of Aubagio in 89 people with RIS (Frenay and colleagues. AAN 2022; P5.011). Results from at least one of these trials are expected later this year.
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