When it comes to initial treatment selection for relapsing-remitting multiple sclerosis (RRMS), there is one question that has yet to be answered: Is it better to start with potentially safer moderately effective disease-modifying treatments (DMTs) or to hit the disease immediately with a high-efficacy DMT that may be more effective but carries more risks?
In a recent opinion article published in the journal Lancet Neurology, Daniel Ontaneda, MD, a neurologist at the Cleveland Clinic, addressed the controversies surrounding early treatment selection for people with RRMS, stressing the variability of initial treatment selection and the weak existing data that guides those choices.
“I think the truth is we don’t have a lot of data to inform that [treatment] decision. Clinicians many times will make that decision based on their overall assessment of how active they think the MS is, also based on patient preferences for medication, how much risk the patient is going to take, and how much risk the physician is going to take as well by prescribing that medication,” Ontaneda said in an interview with Multiple Sclerosis News Today.
The traditional treatment approach for RRMS advocates the use of moderately effective DMTs (also called low-to-moderate therapies, or LMTs) — given as injections in the muscle (intramuscular) or under the skin (subcutaneous), or as oral medications — which generally have good safety profiles.
LMTs are given in escalating steps, where patients are switched to another DMT in the presence of breakthrough disease activity, i.e., relapses or new lesions shown by magnetic resonance imaging (MRI).
The alternative approach to LMTs involves first-line treatment with high-efficacy DMTs (HETs) — all monoclonal antibodies delivered by infusions into the vein (intravenous administration) — with potential exposure to greater risks.
There are four medications currently considered HETs: Tysabri (natalizumab, by Biogen), Lemtrada (alemtuzumab, by Sanofi-Genzyme), Ocrevus (ocrelizumab, by Genentech), and rituximab — an off-label therapy, marketed as Rituxan in the U.S. by Genentech and Biogen, and as MabThera by Roche in Europe.
But the question remains: Which initial treatment strategy is best for relapsing forms of MS?
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