Real-World Study Finds Better Outcomes in MS After Early Intensive Therapy

Due to continued uncertainty around how aggressively to treat early multiple sclerosis (MS), a group of researchers recently analyzed long-term outcomes in a population-based cohort according to initial treatment strategy.

The results, published in JAMA Neurology, found that in a real-world setting, long-term outcomes were more favorable following early intensive therapy when compared with first-line moderate-efficacy disease-modifying therapy (DMT).

Data were collected from January 1998 to December 2016. An analysis was performed shortly thereafter in January 2017. A total of 720 patients were prescribed a DMT, of which 592 were then included in the study. Patients were then further classified according to first-line treatment strategy: high-efficacy, early intensive treatment (EIT); or moderate-efficacy DMT, escalation (ESC).

In total, 104 patients (17.6%) had been prescribed an EIT, while 488 patients (82.4%) began treatment with a DMT. Of the 488 patients originally prescribed a DMT, 58 (11.9%) subsequently escalated treatment to an EIT. This intensification of treatment was caused largely by relapses. The median time to sustained accumulation of disability (SAD) was 6.0 (95% CI, 3.17-9.16) years for those in the EIT arm, and 3.14 (95% CI, 2.77-4.00) years for patients in the ESC arm (P = .05).

For the patients within the ESC group who escalated to EIT as a second-line treatment, the median time to SAD was 3.3 years (95% CI, 1.8-5.6), compared with the EIT group log-rank test (P = .08). After the investigators adjusted for relevant covariates, there was no identified difference between the groups in risk of SAD; however, of the patients who escalated to EIT, 60% were observed to develop SAD while still receiving initial moderate-efficacy treatment prior to escalation.

Overall, investigators found that long-term outcomes were favorable following early intensive therapy versus first-line moderate-efficacy DMT. Importantly, the study authors noted that “contemporary surveillance strategies and escalation protocols may be insufficiently responsive. This finding is particularly relevant as patients in real-world practice are typically selected for an EIT approach to therapy on the basis of clinical and radiological features predictive of a poor outcome.”

Based on these findings, the authors believe that there is a need to conduct a prospective randomized clinical trial in the future.

Reference

Harding K, Williams O, Willis M, et al. Clinical outcomes of escalation vs early intensive disease-modifying therapy in patients with multiple sclerosis [published online February 18, 2019]. JAMA Neurol. doi:10.1001/jamaneurol.2018.4905