#AAN2018 – New AAN Guideline Favors Advising Patients to Use DMTs Early in Disease Course

A new American Academy of Neurology (AAN) guideline recommends that multiple sclerosis (MS) patients in general be counseled to start treatment with disease-modifying therapies (DMTs) as early as possible.

Considerations on switching and stopping treatments are also presented in the guideline.

The report, “Practice guideline recommendations summary: Disease-modifying therapies for adults with multiple sclerosis: Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology,” was published in the journal Neurology, and presented at the 2018 AAN Annual Meeting, which took place April 21–27 in Los Angeles.

Both the Multiple Sclerosis Association of America and the National Multiple Sclerosis Society endorse the new guideline.

Unlike treatments that help to control MS symptoms, DMTs aim to alter disease course by reducing the number of relapses and slowing disease progression.

“The treatment landscape for people with MS has changed dramatically over the last decade,” Alexander D. Rae-Grant, MD, the guidelines’ lead author with the Cleveland Clinic, said in a press release. “We now have a number of disease-modifying therapies to choose from that may help treat MS by changing how the disease affects people over time by slowing the disease process.”

AAN experts reviewed scientific studies on the use of DMTs for MS. They aimed to develop recommendations on starting, switching, and stopping DMTs in patients with relapsing-remitting, secondary progressive, or primary progressive MS, as well as isolated syndromes of demyelination, which refers to the loss in nerve fibers of the protective layer called myelin.

A total of 30 recommendations were developed, including 17 on starting DMTs and who should take them, 10 on switching DMTs, and three on discontinuing treatment.

“This practice guideline reflects the complexity of decision-making when considering initiating, switching, or stopping DMT use for MS,” the team wrote. As such, it includes recommendations as to when physicians should begin counseling patients about DMTs, and issues like treatment adherence, cost, and possible side effects that need to be considered.

The authors found that starting treatment as soon as possible can be better than going without early treatment, because “MS usually gets worse over time.”

According to the guideline, several medications show strong, moderate or low evidence of being able to slow disease processes like relapse rates. In cases in which MS patients experience relapses while on treatment, the experts recommend switching to a medication with a lesser risk of returning disease activity.

The guideline also addresses cases of patients who may consider stopping treatment when their disease is stable. Present evidence on this topic is scarce, the experts noted, and studies analyzing the benefits and risks of stopping MS therapies are needed.

Determining which treatment — and in which order — would be best for a given patient still needs a universally accepted approach. Likewise, a blood test to monitor whether a certain MS medication is working is also lacking. Because some therapies present risks for reproductive health in both men and women, the guideline offers recommendations related to pregnancy and DMT use by female patients. The authors also recommend  that doctors monitor a patient’s plans regarding pregnancy.

MS patients should weigh the benefits and risks of any therapy with their physician before starting, switching or stopping the use of an MS drug, the guideline adds.

Future updates are planned, as researchers noted that a re-analysis may be needed in light of continuing advances in MS research.