Friday, 22 June 2018

Guest post: A snapshot of current disease modifying therapies

There are many disease modifying therapies (DMTs) available for people with Relapsing MS in 2018. DMTs work to prevent MS relapses in the future, and to minimize new MRI activity over time. With many options, it can be hard to decide which therapy to start on, or which one to switch to. 


Sometimes, a physician may have a preference for starting one therapy over another. However, most of the time, the health care provider and person with MS will work together in “shared decision-making” to decide which disease modifying therapy is right for them.


This is a ‘snapshot’ summary of the disease modifying therapies currently available. I've created two tables to help in outlining the DMT options: (1) First-Line Disease Modifying Therapy Options; and (2) Second/Third Line Disease Modifying Therapy Options. 

These tables are to be used as a ‘conversation aid’ in the discussion and education around DMT choices. Sometimes, the options can be different for first-line vs second-line therapies in different countries.


In the tables, the DMTs are organized into those taken by mouth (oral), injections (either under the skin – subcutaneous, or in a muscle – intramuscular), and intravenous (given through an IV in a vein). 

The vertical columns outline how often each medication is taken; how much relative relapse reduction was seen in clinical trials of the drug; what is different about each drug; a brief summary of each drug’s side effects; labwork schedule for side effect monitoring; and, for the first-line DMTs, whether they have to be refrigerated. The information contained within the tables comes from each Canadian DMT product monograph.


The tables don’t (and can’t) directly compare relative effects of reducing future MS relapses between the DMTs. This is because usually the DMT drugs have not been compared “head-to-head” in clinical trials. Instead, the tables give an overall idea of each DMT’s effectiveness against future MS activity (eg: relapses and MRI). Not all of the possible side effects or serious complications for each DMT are described.

The most common or bothersome side effects are mentioned to focus discussion, and to avoid information overload. 

With shared decision making, we go through each option, usually narrowing down to two or three choices. Then, before a final decision is made, more extensive information is given about the “short-listed” DMTs to take home.






Conclusion:
In making choices about which DMT might work, remember that each person responds to each DMT differently. What might work well for one person may not work for another person. What might work at one time of a person’s life, may not work at another (ie: if trying to become pregnant). Remember, that if a DMT is not tolerated, if side effects are experienced, or if a DMT is not working (ie: ongoing relapses and MRI activity), that there are other DMT options to consider.


When a person with Relapsing MS is on the right DMT, their relapses will settle, their MRIs will be more stable, side effects will be bearable, and they are less likely to have disability in the future.


by Penny Smyth



Penny Smyth has been a clinician-educator MS neurologist since 2004. She did her MS fellowship training at the University of British Columbia MS Clinic, and currently practices at the Northern Alberta MS Clinic, in Alberta, Canada. She contributes to a number of MS clinical trials, and works in education for medical trainees and for people with MS. She also has interests in medical professionalism, and is the Associate Dean, Professionalism for the Faculty of Medicine & Dentistry at the University of Alberta.


Conflicts:
I have done education and consulting work with all of the DMT companies and the MS Society of Canada, donating or abstaining from honoraria: Roche Canada; EMD Serono Inc; Novartis Pharmaceuticals Inc; Biogen Idec Pharmaceuticals Inc; Sanofi Genzyme Pharmaceuticals.

[Editor's note: 

1. Apologies for the enormous size of the images, which may distort the post on your screens. The text in the tables was unreadable in a smaller format.
2. If you would like these tables in PDF format to use in your next appointment, please email rDOTaldam [at] qmulDOTacDOTuk]

14 comments:

  1. Replies
    1. As far as I am aware, only Lemtrada has released actual public stats on brain atrophy reduction.

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    2. I haven't mentioned impact of various DMTs upon brain atrophy in the charts. This is because even though the rate of brain atrophy is more associated with disability, it is hard to measure brain atrophy reliably on clinical MRIs. So, even though brain atrophy can be a valuable measure to look at the impact of DMTs in a research setting, it is not as helpful in a clinical setting as yet.

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    3. The above comment was written by Penny, who wrote the article.

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    4. Please share with Penny: Thank you for your response

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  2. I see that Tecfidera can affect the liver, does that make it unsuitable for someone with fatty liver?

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    1. Tecfidera can affect the liver. When someone has problems with their liver already, it would depend on how severe their liver problem is, and/or what the cause of their liver problems might be. I would suggest talking to your doctor first about your particular situation to see Tecfidera might be an option for you. Then, the liver is monitored quite closely on the Tecfidera with labwork monthly for the first 6 months. If Tecfidera is an option, then your liver function will be monitored, and if your liver enzymes start increasing too much, you may need to stop the drug.

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    2. The above comment was written by Penny, who wrote the article.

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  3. Thank you very much for posting this, it’s maddening the lengths pharma will go to in order to word their literature in ways that paint their drugs in the most positive light by getting creative with how percentages are used, usually in ways that have nothing to do with overall relapse reduction rates, confusing patients. I personally found this extremely frustrating and had to build my own table at one point to get a clear picture prior to choosing a DMT. Some of it was terribly misleading. Overall comparison using the same metric is sooooooooo incredibly helpful, although everyone has a responsibility to verify sources personally. Much appreciated :)

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    1. The above comment was written by Penny, who wrote the article.

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  4. You say that after 2 treatments of lemtrada further treatments are on a case-by-case basis is that true? I thought the 3rd treatment was not yet approved

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    1. Most people stabilize with their MS after 2 treatments of Lemtrada. About a third of people require a 3rd set of infusions at some point, and a small percentage require a 4th set of infusions.

      I believe that in some countries, only the first 2 sets of Lemtrada infusions are covered by insurance. It will depend on where you live and your particular insurance coverage, as to whether the 3rd and 4th sets of infusions are covered by insurance or not. That is why I said that further treatments are on a case-by-case basis. Because it will depend on your MS activity (relapses and MRI changes) and insurance coverage.

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    2. The above comment was written by Penny, who wrote the article.

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