Optimizing the initial choice and timing of therapy in relapsing-remitting multiple sclerosis

Abstract

With 12 available US Food and Drug Administration approved medications for the treatment of relapsing multiple sclerosis (MS), choosing an initial therapy is no longer a straightforward task. Each disease-modifying therapy (DMT) has a distinct risk-benefit profile and each patient is an individual. Therefore, the development of a simple algorithm to apply in selecting initial therapy is not feasible. Instead, the prescribing physician must consider many factors related to the treatments themselves, such as efficacy, safety, and tolerability, while also taking into account a particular patient's disease characteristics, personal preferences, comorbid illnesses and reproductive plans. The efficacy of each drug may be assessed through clinical trial data, although these data are limited by scarcity of direct comparisons among the different agents and lack of availability of biomarkers to predict an individual patient's response. Differences in safety profiles help to distinguish the various DMTs and influence selection of agent; both the known safety concerns, which can be addressed with risk mitigation and monitoring strategies, and the potential for yet undiscovered safety issues must be assessed, and an individual patient's comfort level with the risks and ability to comply with monitoring must be determined. Potential issues related to tolerability, which largely relate to matters of patient personal preference and lifestyle, should also be factored into the decision-making process. With regard to the timing of therapy initiation, it must be acknowledged that long-term benefits of early DMT have not yet been definitively demonstrated. Nonetheless, starting DMT early in the MS disease course has been shown to have a beneficial effect on relapse prevention, and appears to curtail the atrophy and neurodegenerative changes that are now known to begin at disease onset. Although under certain circumstances there are acceptable reasons for deferring treatment, it is generally recommended that DMT is initiated early in the disease course.

Modeling the impact of patient treatment preference on health outcomes in relapsing-remitting multiple sclerosis

“…Multiple sclerosis (MS) is a chronic and progressive disease that typically presents as relapsing-remitting MS (RRMS), which is characterized by periodic acute exacerbations of disease activity (relapses) followed by periods of remission [1][2][3][4][5] . There are several disease-modifying drugs (DMDs) available that help control the condition and delay disability progression [5][6][7][8] . Given the chronic and progressive nature of MS, patients will typically remain on a DMD indefinitely 9 ; however, it is quite common to switch to another DMD due to a reduction in effectiveness and/or the occurrence of adverse events (AEs) on the current DMD 9,10 .…”

Development of Glatopa® (Glatiramer Acetate): The First FDA-Approved Generic Disease-Modifying Therapy for Relapsing Forms of Multiple Sclerosis

“…Many US Food and Drug Administration (FDA)–approved disease-modifying therapies (DMTs) are currently available in the US market for patients with relapsing forms of MS, including interferon beta-1b (Betaseron® 4 , Extavia® 5 ), interferon beta-1a (Avonex® 6 and Rebif® 7 ), glatiramer acetate (Copaxone 8 ), natalizumab (Tysabri® 9 ), fingolimod (Gilenya® 10 ), teriflunomide (Aubagio® 11 ), dimethyl fumarate (Tecfidera® 12 ), alemtuzumab (Lemtrada® 13 ), peginterferon beta-1a (Plegridy® 14 ), and daclizumab (Zinbryta™ 15 ). 16 - 20 In general, the currently available medications primarily target the mechanisms that underlie inflammation. Early and ongoing treatment helps to minimize early inflammation, reduce damage in nerve fibers (axons), and reduce loss of brain tissue.…”

Optimization and stratification of multiple sclerosis treatment in fast developing economic countries: a perspective from Qatar

“…Although the etiology of MS remains largely unknown, there is strong biological evidence of an autoimmune pathogenesis sustained by migration of autoreactive T and B cells, as well as macrophagesreactive against one or more unidentified myelin or neuronal antigensinto the CNS 1 . This early stage immune-mediated assault leads to multifocal demyelination and axonal loss, which ultimately results in brain and/or spinal cord atrophy, with significant cognitive changes as observed even in the early course of the disease 2 . The chronic stage is characterized by a more progressive neurodegenerative process.…”