The American Academy of Neurology (AAN) has just released some new guidelines about when to begin, change, and end disease-modifying therapies (DMTs) that are used to treat MS patients. The guidelines, published on April 23, encourage aggressive treatment when symptoms of MS first appear. They’re also patient-centric. And that, IMHO, is wonderful.
The list has several recommendations, including 17 about when to begin, 10 about when to change, and three about when it’s reasonable to end a DMT. Following are some of the highlights.
Starting a DMT
A news release announcing the guidelines makes it clear: “For most people, it’s better to start taking drugs for multiple sclerosis (MS) early on rather than letting the disease run its course.” According to the guidelines:
- Doctors should discuss the benefits and risks of DMTs even if the patient has only shown minimal symptoms and hasn’t yet reached the level that would rate a definitive MS diagnosis. If the patient and doctor decide that the potential rewards outweigh the risks then the DMT should be prescribed.
- If a patient’s disease is highly active, treatment with Tysabri, Lemtrada, or Gilenya should be used because they’ve shown better results at halting progression than treatment with the older beta-interferon therapies Avonex, Betaseron, and Copaxone.
- Because it’s the only DMT that’s been shown to slow progression in primary progressive MS, doctors should offer Ocrevus to people with PPMS if they’re likely to benefit from it, unless the risks of that treatment outweigh the benefits.
- The fact that a patient can’t afford a DMT shouldn’t stand in the way of that patient receiving the treatment. Doctors should help their patients find payment assistance for the recommended treatment. If that’s impossible, then prescribing the less-optimal, but also less costly, azathioprine or cladribine would be appropriate. Something, in other words, is better than nothing.
There are two other, very important, recommendations when starting a DMT. One is devoting one entire session with a patient to discussing treatments after an MS diagnosis is made. That’s because the patient might not recall much information from the session in which a diagnosis is given. The other is considering the patient’s lifestyle when deciding a treatment. This includes how the treatment is administered (e.g. pill, shot, infusion), as well as its efficacy, adverse effects, and cost.
- A patient has been using a DMT long enough for the treatment to take full effect.
- The patient has been conscientious about using the therapy.
- The patient has had one or more relapses, an MRI has detected two or more unequivocally new lesions, or an examination shows that disability has increased over a one-year period.
A few months ago, I wrote about some research that looked at whether there’s a point at which a patient might stop using a DMT. A patient’s age, disease duration, relapse history, and MRI activity all play into this decision.
Doctors should advise MS patients who are stable (no relapses, no disability progression, stable imaging) to continue their current DMT, but they might decide to try a period without therapy. If so, ongoing follow-up should occur and the decision to discontinue the treatment should be periodically reevaluated.
Doctors may advise discontinuation of a DMT in people with secondary progressive MS (SPMS) who haven’t been ambulatory (EDSS 7 or greater) and who do not have ongoing relapses (or gadolinium-enhanced lesions on MRI activity) for at least two years.
To me, as someone who was diagnosed with MS nearly 38 years ago and who has been treated with four DMTs (I hope Lemtrada is my last), these AAN recommendations are reasonable and sensible. I applaud them and hope that neurologists take them to heart.
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