Early intensive treatment gives better outcomes

• New study shows that early use of high efficacy treatment for MS improves long term disability outcomes, rather than starting on a moderately effective therapy and escalating to a stronger medication.
• There has been much debate about the best approach to find the optimal treatment for individuals – whether to start with moderately effective therapies and switch to more intensive therapies as necessary, or start with intensive treatment straight away.
• A new study has shown that compared to people who started on moderately effective therapies, those who start on stronger medication have better long term disability outcomes.
• This highlights the need for improved access to stronger MS medications as a first line therapy in MS.

There are now a range of disease modifying therapies available for relapsing-remitting MS that have been shown to suppress relapses to varying degrees. These medications fall broadly into two groups, those that are moderately effective at suppressing relapses and those that are highly effective at suppressing relapses. Often, the stronger medications have been associated with more serious potential side effects and require careful consideration of the full clinical picture before use.

Access to the full range of MS medications varies widely around the world. In some cases prescribing is limited to the moderate efficacy medications first, with use of the higher efficacy medications restricted to second-line use (second-line use is when the first treatment didn’t work or had adverse side effects and so a second-line treatment is prescribed). Even where all types of medications are available and suitable, making treatment choices can still be challenging.

Traditionally, starting with the more intensive treatments has been reserved for people with very active MS. More recently, there has been a push towards treating people earlier with stronger medications . Research has intensified to identify the best strategy to improve the longer-term outcomes for people with MS. Researchers are investigating whether is it better to start treatment on a highly effective medication and risk the possible side effects, or start with a more moderately effective medication and escalate to a higher therapy as necessary.

Now a new study, published in the medical journal JAMA Neurology  has compared the long-term outcomes of people being treated with these two strategies. The research team took a group of 592 people being treated for MS in Wales, United Kingdom and tracked them over five years.

After five years, information about clinical outcomes was available for 41 people who were given early intensive treatment (with alemtuzumab and natalizumab) and 138 who were initially treated with moderately effective drugs (including interferons, glatiramer acetate, dimethyl fumarate, fingolimod, and teriflunomide), and were given the option to escalate to the more intense treatments as needed.

Since people with more active disease are usually given more aggressive treatments, the people in the early intensive treatment group started off with higher levels of relapses. The study showed that the rate of relapse improved across the board when people were treated with disease modifying therapies, irrespective of the treatment strategy used.

The group of people who were treated more intensively also had a smaller change in their expanded disability status scale (EDSS) – a clinical measure of disability due to MS. Those on intensive medications had an average increase of 0.3, while those on the moderately effective therapies increased by 1.2 over the five years.

60 per cent of those who started on a moderately effective therapy had reached a sustained level of disability before they were escalated to a more intensive therapy. This highlights the early window of opportunity to prevent disability accumulating and the need for better monitoring methods to identify and respond earlier when treatments are failing. The reduction in relapse rates for the intensive therapies were similar whether they were used as the first- or second-line choice, implying that they remain effective even if there is a delay in their administration.

This study shows that relying on moderately effective therapies with the choice to switch to more effective therapies is not necessarily the low risk strategy that it appears to be. For some people with MS it may not prevent long term disability accumulation. This underlines the need for improved access to the higher efficacy medications as a first-line choice.

Each person’s situation is unique and decisions about any MS treatments, taking into consideration the potential benefits, risks and side effects for you as an individual, should be made in careful consultation with your medical team. 

With thanks to MS Research Australia – the lead provider of research summaries on our website.