An analysis of data from 24 Italian MS centres has identified factors associated with an early change of disease-modifying therapy (Sacca et al. Mult Scler 2018; epublished July 25, 2018).
Total enrolment was 3025 patients. Overall, 48% of patients switched treatments in the first three years of starting a DMT. Factors associated with an early switch due to lack of efficacy included the presence of spinal cord lesions (hazard ratio 1.46), diagnostic delay (HR 1.23), and higher baseline EDSS score (HR1.17). Switching due to lack of efficacy was less likely with natalizumab (HR 0.13), teriflunomide (HR 0.21), fingolimod (HR 0.50), and dimethyl fumarate (HR 0.60) compared to an interferon.
Switching due to intolerance or safety considerations was less common with fingolimod (HR 0.35), dimethyl fumarate (HR 0.57) and glatiramer acetate (HR 0.61) compared to an interferon. Switching due to intolerance/safety was more common in patients with comorbidities (HR 1.28) and those on natalizumab (HR 1.43).
A separate study also reported that patients with higher socioeconomic status were more able to access second-line therapies (Calocer et al. PLoS One 2018;13:e0191646).
While several groups have outlined clinical/radiological criteria for an inadequate treatment response, many patients are not switched despite evidence of worsening disease (see also Exploring therapeutic inertia in multiple sclerosis, NeuroSens, July 11, 2018).
In the EPIDEM retrospective study reported earlier this year, data were analysed for MS patients treated for at least two years at outpatient centres in Germany (Schmidt et al. Ther Adv Neurol Disord 2018;11:1756285617749802). Overall, 34.0% of treated patients experienced >1 relapse in the previous 2 years, 21.0% had new MRI activity, and 20.1% had significant worsening of their EDSS score. Despite evidence of ongoing disease activity, 70.6% of patients with relapses and 50.3% of patients with EDSS progression were assessed as clinically stable by their neurologist. A change of treatment was considered in 22.8% of patients with relapse activity, in 37.8% of patients with MRI activity, and in 20.1% of those with EDSS progression.
The authors concluded that the current paradigm of low tolerance for disease activity and for early treatment optimization have not been turned fully into action.