July 16, 2020 | News | Living with MSMS Treatments

When is the time to stop treatment?

In recent years, an important question has emerged about the use of disease-modifying therapies (DMT) to control MS: does there come a time when there’s little more to be gained from treatment? It’s an especially timely question during the current COVID-19 pandemic.

Behind this question are several considerations. It’s well known that the frequency of inflammatory flare-ups (relapses) declines as a person gets older, which may be because the immune response becomes less robust due to aging. It may also be because of the nature of MS itself. Some researchers have suggested that after many years, MS “burns out”, with the level of inflammation and tissue damage declining to what is seen with normal aging (Frischer and colleagues. Brain 2009: 132;1175-1189). Since DMTs primarily target inflammation, there would be less treatment benefit if less inflammation is present.

Secondly, if there is less benefit, the potential risks associated with treatment may be less justifiable, especially in older people who have other medical conditions and a higher risk of complications such as infections. Thirdly, DMTs have generally not been tested in older people so their safety profile in people older than age 65 (age 55 in some cases) isn’t known.

Of course discontinuing treatment also has economic implications. Many people like the idea of stopping treatment (no more hassles, no more co-pays), and insurers would certainly welcome a reason to cut off coverage of expensive MS medications.

Several groups of researchers have started to look into whether some people with MS can stop treatment and the largest analysis to date has just been published (Schwehr and colleagues. Drugs Aging 2020;37:225-235). The study was done by the BeAMS Study Group, which uses computer modelling to estimate outcomes. The model assumed that a person was aged 55 or 70 years, had experienced no relapses in the preceding five years while on treatment (an interferon, Gilenya or Tysabri), and had some disability but could walk unaided (i.e. no cane or walker) for 100 metres. These criteria reflect a person with mild to moderate disease course with little or no disease activity for a five-year period. In that scenario, continuing treatment provided little or no benefit. In such analyses, the benefit is typically measured in units called ‘quality-adjusted life-years’; in this study, the maximum benefit was estimated to be a matter of a few life-days – so scarcely worth the effort.

An earlier study compared people continuing treatment with those who stopped. The people in this study had experienced no disease activity (relapses or MRI lesions) for at least two years beforehand. Overall, people who stopped did not have a higher risk of disease activity or worsening disability if they were older than age 45 (Hajime and colleagues. Mult Scler Relat Disord 2019;35:119-127). However, people younger than age 45 were at risk of worsening disease if they went off treatment.

These results are preliminary, but they suggest that in some situations it’s worthwhile to have a conversation with your neurologist about whether you can stop treatment. Certainly, older people (age 60+), who are at higher risk from COVID-19, may be candidates for stopping during the pandemic. It may also be a consideration for people in their late fifties who haven’t shown any disease activity (relapses or new MRI lesions) for several years. However, stopping treatment shouldn’t be done on your own – you’ll need to talk to your neurologist and MS nurse beforehand. And they’ll need to monitor you more closely so they can re-start treatment promptly if your MS flares up again.

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