Great debate: Should potent and expensive MS therapy be used first line?

Multiple sclerosis

By Nicola Garrett

28 May 2019

Two leading experts took to the stage during ANZAN ASM to debate a controversial topic in neurology – should high-expense high potency MS therapy be used first-line in patients with MS?

Dr Tomas Kalincik

Taking on the ‘yes’ side of the debate Associate Professor Tomas Kalincik from the Royal Melbourne Hospital told delegates that recent statistics showed the number of people living with MS in Australia increased by just over 20% from 21,283 in 2010 to 25,607 in 2017, with a total cost to society of $1.75 billion.

“That cost increases in Australia from roughly $30K per year to close to $120K per person per year with increasing disability…people with more advanced disease cost us more to look after,” he told delegates.

“In the absence of therapies routinely available to clinicians, MS is a one way street.  We need to prevent the disability, and its associated costs, rather than wait for the disability to develop… because there is no way back,” he stressed.

Evidence showed that high potency treatments were effective at preventing disability in patients.

For example, a trial published in JAMA earlier this year by the MSBase Study Group showed that initial treatment of patients with relapsing-remitting MS with disease-modifying therapies fingolimod, natalizumab, or alemtuzumab was associated with a 34% lower risk of conversion to secondary progressive MS compared with interferon beta or glatiramer acetate therapy.

“This [figure] is not a marginal difference,” Professor Kalincik noted.

According to Professor Kalincik the crux of the conversation was how to identify the patient with severe disease who would require an aggressive approach to treatment.

“Unfortunately we haven’t been very successful at isolating that group of patients who would do fine on low efficacy therapy over the long-term,” he said.

He noted that it was not only the dichotomy of high efficacy vs low efficacy that required thought but also the timing of treatment.

Referring to the JAMA study Professor Kalincik noted that escalating treatment from glatiramer acetate or interferon beta to fingolimod, alemtuzumab or natalizumab within 5 years of disease onset was more effective in reducing risk of conversion than waiting longer than 5 years, with HR 0.76 (CI 0.66-0.88) and absolute risk of 8% (25 of 307) vs 14% (46 of 331).

However, he cautioned that there was no such thing as a free lunch and every treatment had a cost.

“When we are talking about costs were are talking about side effects…I appreciate there is probably a perception, rightfully so, of a superior side effect profile of low efficacy therapies however when we look at an overall summary of the side effects its not immediately easy to pick out the low efficacy treatments,” he noted.

Prof Jan Hillert

“Worsening of disability is best prevented by early introduction of potent therapies..when in doubt, over treating is better than allowing MS to progress,” he concluded.

Addressing the ‘no’ side of the debate visiting expert Professor Jan Hillert from the Karolinska Institute in Stockholm told the audience that an escalation strategy using DMTs first line was modestly efficacious yet safe.

Whereas using high potency DMTs early was high efficacious but “somewhat risky”.

He said that the questions that needed to be asked were whether the differences between the two treatment strategies were important and significant long-term, and whether we needed head-to-head trials

He concluded by displaying a slide which read: “High expense high potency MS therapy should be used first line in patients with MS? No (t yet).”

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