The MSVirtual 2020 meeting brought together clinicians and researchers from the European Committee for Treatment and Research in Multiple Sclerosis (ECTRIMS)  and its American counterpart (ACTRIMS). Australian clinicians made many notable presentation, of which three are highlighted here

Natalizumab  improves symptoms more than other DMTs

Natalizumab appears to have greater effects than other disease modifying therapies (DMTs)  on some MS symptoms and on employment outcomes, according to Australian data. A presentation of prospective data from the Australian MS longitudinal study by Associate professor Ingrid van der Mei of the Menzies Institute for Medical Research, Tasmania, showed that compared to other DMTs, natalizumab was associated with superior effects over time on improving balance, vision symptoms, sensory symptoms, bladder symptoms, sexual dysfunction, and feelings of anxiety. Based on 2836 patient-reported observations from 2015 to 2017, natalizumab was also associated with a reduction in work absenteeism compared to worsening for other DMT. However unlike other DMTs, there was no evidence of an effect of natalizumab over time on improving Health-Related Quality of Life (HQRQoL). The use of natalizumab was associated with a marginal decrease in self-reported progression in the previous 12 months while the use of injectable DMTs and fingolimod were associated with an increased self-reported progression.

Postpartum relapse risk remains in era of high efficacy therapy

For pregnant women with MS the early postpartum period remains a period of vulnerability for disease rebound despite the availability of high efficacy therapies, data from the MSBase registry show. Disease activity in 1640 pregnancies spanning the modern era (2011-2019) and previous era of 2005-2010 and pre 2005 were reviewed by researchers from the Alfred Hospital, led by Dr Wei Yeh. They found that the preconception annualised relapse rate decreased over time (pre-2005: 0·58, 2005-2010: 0·40, modern: 0·29. The ARR decreased during pregnancy in all periods to reach similar troughs in the third trimester, and rebounded in the  first three months postpartum. Early postpartum relapse was predicted by   preconception use of high-efficacy DMT (hazard ratio 2.1) although women on no DMT were also at risk of postpartum relapse, relative to women on low-efficacy DMT (HR 2.7 ). Other risk factors for relapse included conception EDSS ≥2, higher preconception and in-pregnancy ARR. The study found that DMT reinitiation, particularly of high-efficacy DMT (HR 0.17was protective against postpartum relapse. And in the modern era, 4.5% of modern pregnancies had confirmed disability progression after delivery. Women who breastfed were less likely to relapse (HR 0.63 and this was predicted by higher pregnancy and postpartum ARR, with postpartum ARR remaining independently predictive in multivariable analysis (HR 1.5 ).

Real world cladribine outcomes from MSBase registry

Real-world outcomes data for patients treated with cladribine tablets show that first-line use is uncommon and the relapse rate is low. Date from 576 patients from Australia and Europe treated with cladribine, derived from the MSBase Registry data, showed that the median age at startin was 45 years, disease duration since clinically isolated syndrome was 12.6 years and median EDSS was 2.5. Of the cohort, 496 patients had relapsing-remitting MS (RRMS) of whom 13% started cladribine tablets as first line therapy. For other patients the most common immediate prior therapies were fingolimod (17%), followed by natalizumab, teriflunomide and dimethylfumarate (all approx 10%).The annualised relapse rate (ARR) on cladribine tablets was 0.12, compared to a pre-cladribine rate of 0.38. Treatment persistence was 95% after 12 months and 92% after 24 months.