Why pills became the most popular first DMTs for MS

A new study reveals changes over 20 years of MS treatments

by Ed Tobias | July 21, 2023

Note: This column describes the author’s own experiences with several disease-modifying therapies for multiple sclerosis. Not everyone will have the same response to treatment. Consult your doctor before starting or stopping a therapy.

Times, they’ve been a-changing for disease-modifying therapies (DMTs). When I was diagnosed with multiple sclerosis (MS) in 1980, there were no DMTs. The first, the injectable Betaseron (interferon beta-1b), was approved by the U.S. Food and Drug Administration (FDA) in 1993 for relapsing-remitting MS.

A few years later, I was thrilled to be included in the Phase 3 clinical trial of Avonex (interferon beta-1a), the second injectable, even though it required a self-injection into my calf once a week. Injectable DMTs were the only game in town until 2010, when a pill, Gilenya (fingolimod), received FDA approval.

Afterward, it seemed inevitable that, as a study in JAMA Neurology reported on July 10, the days of injectables being the first-prescribed MS treatments would be numbered.

Can elderly MS patients safely stop treatment? Study aims to find out.

The change from shots to pills

The Rutgers University study, based on data from U.S. health insurance companies, analyzed DMT prescribing patterns between 2001 and 2020. It involved 113,583 MS patients, each of whom started at least one DMT over those two decades. During that time period, prescribing an injectable medication as an adult’s first MS treatment declined a whopping 73.8%.

Pin the decline on pills. While oral treatments accounted for only 1.1% of the first DMT prescriptions being written in 2010, by the end of 2020 there were eight pills on the market — and they garnered 62.3% of the initial DMT orders.

Somewhat surprisingly to me, the study showed only a small (3.2%) demand for the highly effective infusions that became available starting in 2004, when Tysabri (natalizumab) was approved. That percentage began to increase after Ocrevus (ocrelizumab) was introduced in 2017, but it only rose to 8.2% by 2020, even though Lemtrada (alemtuzumab) had also become available.

It’s a lifestyle thing

The research suggests several reasons for this preference for pills. They include efficacy, tolerability, safety, and cost — and the cost is often the elephant in the room when treatments are being discussed. Wrap all of these things together and it adds up to lifestyle. As the MS News Today story about this research points out, oral DMTs “have provided an alternative, more convenient form of administration compared with injectable and infusion therapies.”

Over my 42 years of living with MS, I’ve been treated with four DMTs: Avonex, Tysabri, Aubagio (teriflunomide), and Lemtrada. Each helped me to live the best life possible with this illness, but my goal for each medication was slightly different.

Avonex gave me hope that there was finally a medication that might slow my relapses, and it did. Tysabri was an easy monthly infusion that solved the problem of needle fatigue, which I developed after a dozen years of self-injecting.

Aubagio allowed me to continue a DMT after my John Cunningham virus titer levels became concerning. As a pill, it was also the most convenient of the four treatments, but a change in my health insurance made Aubagio unaffordable.

That brought me to Lemtrada. Its efficacy was rated higher than my other three medications in a 2021 classification in the Journal of Comparative Effectiveness Research; its cost was covered by my Medicare insurance; and two series of infusions — each a year apart — fit my lifestyle. I was 68 years old, retired, and had lived with MS for 38 years when I began Lemtrada. I felt its benefits outweighed its risks, and my neurologist and I agreed that it would be my final DMT.

I’m sorry that more people with MS are not being started off with infusions as their treatment, especially because they’re considered to be among the most effective of the DMTs. The reason could be that regular infusions might not fit the lifestyle of many people or it could be fear of the side effects, but I suspect a lot of it has to do with that “elephant” in the treatment room — cost — and the unwillingness of health insurance companies and national health services to cover infusions as first-line treatments. And that’s a shame.

I invite you to share your thoughts in the comments section below and to visit my personal blog at www.themswire.com.

Note: Multiple Sclerosis News Today is strictly a news and information website about the disease. It does not provide medical advice, diagnosis, or treatment. This content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read on this website. The opinions expressed in this column are not those of Multiple Sclerosis News Today or its parent company, BioNews, and are intended to spark discussion about issues pertaining to multiple sclerosis.

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About the Author

Ed Tobias People say to write what you know and Ed Tobias knows about MS. He's lived with the illness since 1980, when he was 32 years old. Ed's a retired, award-winning broadcast journalist and his column combines his four decades of MS experiences with news and comments about the latest in the MS community. In addition to writing his column, Ed is one of the patient moderators on the MS News Today Facebook, Twitter, and Instagram sites. He’s also the author of “The Multiple Sclerosis Toolbox: Hints and Tips for Living with M.S.” Ed and his wife split their time between the Washington, D.C. suburbs and Florida’s Gulf Coast, trying to follow the sun.

Comments

Rachel Ka

The generic form of Aubagio is now available at a MUCH lower cost on Mark Cuban´s Cost Plus pharmacy formulary.

Ed Tobias

Thanks for that info, Rachel. I wrote about Cost Plus about a year ago and noted that genetic Aubagio and Tecifedera were both available on Cuban's service. Unfortunately, they were the only MS DMTs on that site. https://multiplesclerosisnewstoday.com/columns/2022/07/31/medication-costs-mark-cuban-discount-prescriptions/

Heather

I’ve used the oral pill Tecfidera successfully for many years. My neurologist orders blood tests every six months to check for safety. Once I started on Medicare the cost skyrocketed along with Ampyra but supplemented insurance has helped so there is no reason to change my DMT, especially at the age of 67 yrs. old. The generics for both drugs are available but don’t work as well.

Ed Tobias

Hi Heather,

It's crazy with Medicare. They won't pay 80% of the cost of a pill but they will pay 80% of an infusion, because it's done in a doctor's office, hospital or infusion center.

Mody

For me, pills are not the most popular DMTs cause it’s very weak to face this disease comparing with infusion drugs

Ed Tobias

Hi Mody,

That's also pretty much how I feel, although Gilenya is a pill that's considered to be high efficacy.

Matthew W

It is an interesting read to see how medications have changed and progressed in a relatively short amount of time. I feel fortunate to have been diagnosed 5 years ago and then put on Ocrevus. I am VERY thankful for the insurance that we have as I still remember sitting in my neurologists office and asking him what that costs and just about facing off the chair! But I also feel more fortunate to have been diagnosed at an older age, and it does make me wonder what else the treatment may be doing to my body and if I do need it, but who wants to make that bet?
I feel for the folks that cannot get the treatment because of the insurance.Who knows if the insurance companies treated them it may even save them money down the road do to people possibly not having secondary conditions.

Ed Tobias

Hi Matthew,

Thanks for your comments. We all have similar thoughts, I think. So, we do our research and hope the treatment will help. As for insurance, that's an argument in favor of Lemetrada treatments or stem cells, both of which, hopefully, don't continue forever.

Jody Perkins

Did you ever consider stem cell transplantation, HSCT, Ed?

Ed Tobias

Hi Jody,

No. I think cost was a factor, but also an uncertainty about side-effects. Also, by the time I knew enough about aHSCT to consider it I think my progression was past the point where it would have helped very much.

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Why pills became the most popular first DMTs for MS