MS Sequencing Part 7: What is a rational approach?

 

Comment by Dr. Paul Giacomini
NeuroSens survey on sequencing – Part 7

A towering edifice of MS therapies has been built in recent years, but the structure has an exceedingly narrow base of evidence when it comes to how to sequence these agents. How does one construct something that won’t come crashing down – either because of too little efficacy or efficacy deferred, or too great a risk for the benefits that can be achieved? And in devising a blueprint, how does one manage the risk conundrum: younger, less disabled patients generally wish to avoid risk when a more aggressive approach may well change the slope of progression; whereas older, more disabled patients are ready to assume greater risks, when it is likely too late to change the outcome?

In the absence of evidence, some general principles have emerged in recent years that provide a rough guide to sequencing therapies in patients with relapsing-remitting MS.

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When initiating a front-line therapy (injectable or oral), what is the general treatment plan?

At 6 months after initiation, if the patient reported poor tolerability on a front-line DMT but appeared to have an adequate response, what would you do?

At 9-12 months after initiation of a front-line agent, if the patient demonstrated ongoing disease activity (relapses, new MRI lesions), what would you do?

When sequencing therapies, what is your primary clinical goal?

With this goal in mind, what therapy would you most likely use in a patient with an inadequate response to a front-line therapy?

In a patient with ongoing breakthrough disease, which of the following sequences would be most worrisome to you with regard to safety?

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