Older MS patients with stable disease may safely stop DMTs: Study
Discontinuing DMT had no predictive value for relapse risk, disability worsening
People over 60 with multiple sclerosis (MS) who have stable disease may discontinue their disease-modifying treatments (DMTs) without an added risk of relapses or worsening disability, according to a small study.
At that age, only the presence of lesions with active inflammation and an Expanded Disability Status Scale (EDSS) score above 3, indicating at least moderate disability, were significant predictors of a greater risk of relapses or disability progression.
“Retrospective data from this small cohort supports the notion that DMT discontinuation is not likely to affect long-term clinical outcomes in older stable MS patients,” the researchers wrote in the study, “Discontinuation of disease-modifying therapy in MS patients over 60 years old and its impact on relapse rate and disease progression,” which was published in Clinical Neurology and Neurosurgery.
Most DMTs approved for MS suppress or modulate the immune system, which goes awry in MS and causes damage to the brain and spinal cord. However, the immune system becomes less able to mount a response as people age, starting at age 60.
As patients age they’re known to have fewer relapses, with inflammation becoming not as much of a factor in disability, which may result in DMTs being less effective for them.
Determining value of DMTs for older MS patients
A team led by researchers in Portugal sought to determine whether older MS patients can still benefit from DMT use, particularly if they’ve had no signs of disease activity for a long time.
They examined data from MS patients followed at a single center. Participants were over 60 and had stable disease, defined as an absence of relapse or confirmed disease worsening in the two years before turning 60.
A total of 35 patients were included. Most were women (68.6%), with a mean age at diagnosis of 42.1. The majority of patients had mild to moderate MS with a median EDSS score of 3, and 80% were receiving treatment with glatiramer acetate or interferon-based medications.
Only three patients were receiving high-efficacy DMTs at 60 — two were on Gilenya (fingolimod), one was on Tysabri (natalizumab).
Over an average follow-up of 77.1 months (about 6.4 years), 13 patients (37.1%) discontinued their DMT, either due to disease progression or side effects. Most who discontinued had secondary progressive MS and the rest had relapsing-remitting MS. The median age at discontinuation was 63.
At the study’s start, the groups who went on to discontinue and continue treatment were not significantly different in demographics, DMT exposure, and disability scores.
Likewise, at the last follow-up assessment, there was no difference between the groups regarding relapse rates or disability progression after discontinuation. Those who discontinued tended to have higher EDSS scores and greater EDSS changes than those who continued their DMTs, though these differences weren’t deemed significant.
“DMT discontinuation did not seem to influence clinical outcome, equating with the perceived limited effect of continued immunomodulation on older stable and/or progressive patients,” the researchers wrote.
Discontinuing a DMT had no predictive value regarding the risk of relapse or disability worsening during the follow-up, statistical analysis showed. Active lesions on MRI scans at age 60, however, were an independent predictor of relapse risk and having EDSS scores higher than 3 at age 60 predicted the risk of disability worsening.
“Prospective studies on older MS patient cohorts, as well as clinical trials, should be conducted to offer clinicians a practical framework for DMT discontinuation and disease monitoring in this setting,” the researchers said.