Why change therapies?
Many people diagnosed with relapsing-remitting multiple sclerosis go on to develop a secondary-progressive form, in which there is a steady accumulation of disability despite few or no relapses. Since there are few treatment options for secondary-progressive MS (SPMS), it’s best to try to delay the onset of SPMS for as long as possible. But will the current crop of MS medications slow the development of SPMS?
This question was addressed in a new analysis of a database of 1,555 MS patients from 21 countries (Brown and colleagues. JAMA 2019;321:175-187). The study found that starting treatment with a disease-modifying therapy (DMT) was better than remaining untreated. Among those starting on Copaxone or one of the interferons (Avonex, Rebif, Betaseron/Extavia, Plegridy), the risk of developing SPMS over the next 8 years was reduced from 27% (about 1 in 4) to 12% (about 1 in 9). The chances of developing SPMS were also reduced if a person started a DMT within the first few years of being diagnosed compared to putting off treatment for 5 or more years.
Starting treatment with a more potent DMT, such as Gilenya, Lemtrada or Tysabri, lowered the risk of developing SPMS even more. The risk of developing SPMS was 39-63% lower with one of these agents compared to remaining off treatment. Keeping in mind that these medications are generally used in people with more severe or aggressive disease from the outset, there was still a substantial reduction in the risk of SPMS.
The study also found that the risk of SPMS was one-third lower in people who started treatment with Gilenya, Lemtrada or Tysabri rather than Copaxone or an interferon.
However, it should be noted that in many countries, higher-efficacy DMTs aren’t approved for use or won’t be reimbursed by insurers as first-choice agents. So many doctors adopt the strategy of starting a person on any drug that will be reimbursed as an initial therapy (Copaxone, an interferon, Aubagio or Tecfidera), with the view to switching them to a more potent agent as soon as possible.
Does this strategy make sense?
Yes, according to the study. People who were switched from Copaxone or an interferon to a more potent agent within the first five years lowered their risk of SPMS by 24%. Over a 5-year period, that risk was reduced from 14% (about 1 in 7) to 8% (1 in 13).
These findings suggest that starting treatment with any DMT early on can delay the development of progressive disability. A more potent drug can provide an added benefit in delaying disability, especially if it’s started in the first few years after being diagnosed.
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