What treatment is best for me?

The first effective medication to control multiple sclerosis (Betaseron) was introduced almost 30 years ago and the number of treatments has proliferated ever since. With over a dozen options now available, how is someone to know which is the best treatment for their specific situation?

While there are many factors to consider, perhaps the most important are disease activity and personal preferences. Disease activity in this context means the severity of inflammation in the central nervous system – as assessed by relapses and lesions on an MRI. Personal preferences refer to the various features of a drug: how often it is taken, how it is taken (i.e. by injection, orally or by infusion), potential side effects, a person’s level of concern about the side effect profile, and so on.

We can roughly sketch out three “drug eras”. In the first (1994-2010), injectable drugs (Betaseron, Avonex, Rebif, Copaxone) were generally the only option. The second era (2010-2016) saw the rise of oral therapies (Gilenya, Aubagio, Tecfidera). The third era (2016-present) was characterized by the introduction of potent infusion drugs (Lemtrada, Ocrevus). There were some exceptions to these trends, such as the infusion drug Tysabri in 2006, and late arrivals to a category, such as oral Mavenclad in 2017 and the injectable drug Kesimpta in 2021.

The two key developments were making treatment more acceptable with the introduction of oral therapies; and the availability of increasingly potent drugs that were more effective at controlling disease activity for people who needed that.

Having so many different options can be confusing. But it has meant that people with MS are more likely to find something that is more tailored to their level of disease activity and their personal preferences.

These days, the most popular starting therapies are oral drugs (Aubagio or Tecfidera). During treatment, a switch can be made to a more potent drug if disease activity persists. For many people, an oral therapy is adequate to control their MS. One advantage is that these drugs do not have a major impact on the immune response. This means that there is a lower risk of getting an infection, such as a respiratory infection or a urinary tract infection. This issue of infections was viewed somewhat cavalierly, but it acquired new currency during the COVID pandemic, when people became much more aware of the risk of acquiring an infection in their community. There is now a note of caution among doctors about the potential effects of long-term suppression of the immune response – a concern as we enter what may be a COVID endemic time.

Having a broad range of treatment choices has improved the overall management of MS, according to the results of a recent study in Germany (Braune and colleagues. Br Med J Open 2021;11:e042480). The study analysed the NeuroTransData registry of over 17,000 people with MS for three time periods: 2010-2012, 2013-2015; and 2016-2018. Over those three periods, oral therapies became increasingly popular. Overall, 19% of people started treatment with an oral drug in 2010-2012, rising to 52% in 2013-2014 and 55% in 2016-2018. There was a corresponding decline in injectable drugs, from 74% to 40% during those same time periods. These are scarcely a surprising finding: injecting yourself is unpleasant and many people are afraid of needles, which is why oral drugs were introduced in the first place. Oral medications were also the most common choice for people switching off an infusion drug.

Treatment was shown to be highly effective at reducing disease activity. The relapse rate among people taking an oral therapy decreased by one-third between 2010 and 2018. There was also a steady increase in the proportion of people with no relapses or new lesions on their MRI. With treatments overall, the proportion of people who developed moderate disability decreased by 39% over the 8-year period.

The researchers concluded that more treatment options have enabled more people to start a medication, start treatment earlier, and to remain on therapy for longer. They also made the point that treatment choice is a more important consideration than whether one drug is better or worse than another drug in a clinical trial. The best treatment option is the one that satisfies the individual taking the drug – and a person will be more likely to find the right match for their needs and preferences if more choices are available.

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