P.B. is a 57-year-old woman with a 24-year history of relapsing-remitting multiple sclerosis. She was treated with an injectable from 2002-2012. Her last relapse was in 2009. She was transitioned to fingolimod in 2012 because of ongoing MRI changes and increasing tolerability issues.
She has had annual MRIs while on fingolimod. In the first few years she had occasional new lesions, but her MRI has been stable since 2019. She has had no clinical evidence of progression. Her EDSS has been stable at 2.5 for 15 years (bladder 2, pyramidal 2). Her blood work has been stable with a lymphocyte count in the range of 0.3-0.4 x 109/L and normal LFTs. She says she tolerates fingolimod well.
P.B. was recently diagnosed with type 2 diabetes and has been started on an oral hypoglycemic agent. She asks you if she still needs to take fingolimod. She says she has been wondering if she should change or discontinue her MS treatment although she feels somewhat ambivalent about stopping therapy altogether.
The survey is now closed. There were 43 responses. See below for a summary of the answers you provided.
Question 1. Do you think P.B. is a good candidate for treatment discontinuation?
A majority of respondents (53.4%) said she would not be a good candidate due to the risk of rebound disease activity if fingolimod were stopped. Another 2.3% said they would not stop treatment since P.B. had MRI activity within the past 10 years. The remaining respondents said they would stop treatment since the patient’s MS has been stable for many years (13.9%), or because her age and comorbidities put her at higher risk of adverse effects (23.2%).
Question 2. What is your biggest concern about continuing treatment?
Other infections (65.1%) was the greatest concern for most respondents. Other concerns were vascular issues (16.2%), malignancy (9.3%), PML (2.3%), or other issues (6.9%).
Question 3. What is your biggest concern about discontinuing treatment?
The greatest concerns were rebound disease activity (86%) and worsening disease progression (PIRA or SPMS) (14%).
Question 4. Would the decision to discontinue treatment be easier if the patient were receiving interferon-beta or glatiramer acetate?
Most respondents (51.2%) agreed that the decision would be easier since P.B.’s disease was not very active if she was well-controlled on a lower-efficacy agent. However, 27.9% said they would still be concerned about disease recurrence and worsening disability if treatment were stopped, and 2.3% thought P.B. was still too young to discontinue therapy.
Question 5. Would the decision to discontinue treatment be easier if the patient were aged >60 years and had been free of disease activity for >10 years?
The largest proportion of respondents (44.2%) said they would still be concerned about rebound disease activity and would prefer to transition to another DMT before stopping treatment altogether. Another 9.3% said there was no reason to stop since the patient shows good acceptance of the regimen. In contrast, 27.9% said they would stop because the benefit-risk for a patient aged >60 years would be less favourable, and 18.6% noted that there is less treatment benefit in older patients.
View the video commentary from Dr. Caitlin Jackson-Tarlton.