Early treatment with effective DMT holds off RRMS progression

Multiple sclerosis

By Mardi Chapman

17 Aug 2021

Early intervention with a highly effective disease-modifying therapy reduces disability progression in relapsing-remitting MS.

A comparison of two national cohorts with different treatment strategies showed starting with a more effective therapy was superior to commencing a conventional first-line DMT and escalation.

The study, published in JAMA Neurology, compared disability outcomes in Swedish and Danish MS Registry cohorts of 2,700 and 1,966 adult patients with RRMS respectively.

Danish patients were more likely to start treatment with a conventional first-line DMT, primarily teriflunomide compared to Swedish patients (42% v 2.4%).

Danish patients were also less likely than Swedish patients to initiate treatment with a highly effective DMT such as rituximab (0.1% v 17.9%) and natalizumab (4.8% v 11.1%).

The study said Sweden did not receive a full indication for teriflunomide until 2016 – later than in Denmark – and off-label prescribing of rituximab had become more common.

It said the recommendations to initiate DMT and when to escalate treatment in the case of breakthrough disease activity were similar in both countries.

“However, in clinical practice in Sweden, there has been a shift to begin highly effective DMT also in patients with less disease activity or fewer neurologic adverse effects.”

The investigators found the Swedish treatment strategy was associated with a 29% reduction in the rate of post-baseline confirmed disability worsening (CDW) relative to the Danish strategy (HR 0.71; p=0.004).

It was also associated with a 24% reduction in the rate of reaching an EDSS score of 3 (HR 0.76; p =0.03).

The study noted Danish patients had a higher rate of treatment discontinuation and switching. Lack of effectiveness was reported as the most common reason for discontinuing the index treatment.

“In addition, Swedish patients switched to a highly effective DMT more often than Danish patients did, which might have been associated with the more favourable disability outcomes among Swedish patients.”

“This study shows that, for the first time to our knowledge, differences in national treatment recommendations and strategies had a significant association with disability outcomes after a few years of follow-up.”

Professor Simon Broadley, a neurologist and dean of medicine at Griffith University, told the limbic the findings were entirely consistent with has long been suspected but had been difficult to prove. 

“The short story is that if you treat aggressively from the outset, people with MS do better in the long run. This does mean that you might have used an expensive, slightly more involved  therapy… in a few people who weren’t going to need it, but as you can’t identify who those people are, the alternative is wait until people fail a lower therapy which is not good.”

He said most MS specialists in Australia would use the general approach of starting patients on the most efficacious therapy they were willing to accept. 

“Thankfully, our prescribing is not restricted by any algorithm,” he said. 

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