Neurologists share treatment preferences for older adults with MS
Guidelines, clinical trials lacking for the many patients in their late 50s or older
For older adults with multiple sclerosis (MS) who have highly active disease, most neurologists recommend starting treatment with a high-efficacy therapy, according to a survey study.
Neurologists also generally agreed that patients with MS should continue on treatment into the latter decades of life, and that older MS patients can benefit from more rigorous monitoring as well as vaccines for COVID-19 and the flu.
The study, “Treatment of older patients with multiple sclerosis: Results of an International Delphi Survey,” was published in Multiple Sclerosis Journal – Experimental, Translational and Clinical. The work was funded by Biogen.
More than half of all MS patients today are older than age 55
While more than half of people living with MS today are older than 55, clinical trials of potential disease treatments often are limited to younger patients. As a result, data on the efficacy of various therapies in older patients are lacking, making well-informed treatment decisions difficult.
These decisions are further complicated because the immune system tends to weaken as a person gets older. This can help to dampen MS-driving inflammation, but it also increases the risk of infections, especially when using MS treatments that work by suppressing the immune system. Older adults with MS also are more likely to have other co-occurring health problems (comorbidities).
An international team of scientists conducted a survey to better understand how clinicians care for MS patients in their mid-50s or older. The goal was “to identify unique considerations for the care and treatment of older [people with] MS, find consensus of how MS practitioners are managing this patient population, and thereby providing real-world clinical perspectives in MS care.”
Researchers used a survey technique called a Delphi process, where an initial round of surveys is given, then the survey is adapted based on the responses before a second round of surveys goes out. This reiterative process can “add structure to the methodology, help remove bias, and can improve the reliability of the study results,” the researchers wrote.
A first round of surveys was answered by 224 neurologists from nine countries, and the second round was answered by 180 neurologists, most of whom had participated in the first round.
Most of the neurologists were in Europe. The researchers noted that there were some significant differences in responses between respondents in Europe, South America, and the U.S., but said these regional variations were “beyond the scope of this paper.”
High-efficacy therapies favored for newly diagnosed older adults
Survey results showed that the experts generally agreed that special considerations are required in the care of older MS patients — though notably, there wasn’t a consensus on exactly what age constitutes “older” in terms of patient management.
More than half of the neurologists agreed that older patients need more frequent monitoring, and that these patients tend to have less active MS but more substantial disability. Most neurologists reported conducting yearly assessments of cognition and eyesight for their older MS patients.
The many treatments available for MS can broadly be classified into high-efficacy therapies, which are usually very potent at controlling disease activity but also can carry a substantial risk of infections and other side effects, or moderate-to-low efficacy treatments, which are less potent but safer.
Nearly two-thirds (63%) of the neurologists said that they usually recommend a high-efficacy therapy as the initial treatment for older adults newly diagnosed with MS. The most common reasons cited for selecting a high-efficacy treatment were high disease activity and progressive disease.
If the high-efficacy treatment caused unacceptable safety problems, patients could be switched to a lower-efficacy therapy — however, neurologists indicated that most of their older patients did not require such de-escalation.
“A majority of respondents indicated that they considered high-efficacy [treatments] as first-line treatment in newly diagnosed older [people with] MS with highly active disease which, in the absence of specific guidance for the older patient subgroup, is consistent with recommendations for the general population,” the researchers wrote.
Vaccinations seen as important for older MS patients
Most neurologists agreed that people diagnosed with MS earlier in life and with stable disease while on a treatment should continue with that treatment as they age past the late 50s. About a third of the neurologists said they would consider stopping treatment for patients older than age 55 who haven’t had any signs of disease activity for the previous five years.
Most also agreed that they would stop treatment if older patients requested that it end.
Because all the approved treatments for MS work by suppressing the immune system, they can reduce the efficacy of vaccines. Most of the neurologists agreed that older MS patients should get vaccines for influenza, COVID-19, and pneumococcus. Most also said that they would not pause MS treatment for the vaccine, or that vaccine responses would influence their treatment decisions.
“In light of the lack of specific treatment guidelines for [people with] MS [older than] 55 years, this study may be useful in informing the development of evidence-based practice guidelines for older [people with] MS with the goal of improving elderly patient management,” the researchers concluded.
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