Making Treatment Decisions When There Is an Abundance of Options

Despite the benefit of having more choices than ever before to treat patients with multiple sclerosis (MS), the abundance of options has led to more complexity, according to speakers at the 2014 ACTRIMS-ECTRIMS Joint Meeting in Boston, Massachusetts.

In the 1980s just 1 option had been available, but there are currently 12 that patients and providers need to choose between when creating a treatment plan for individuals with MS.

“It seems unlikely that any one drug will address all of the needs for all patients,” Richard Rudick, MD, director of the Mellen Center for Multiple Sclerosis Treatment and Research at the Cleveland Clinic, said.

As a result, he added, treatment plans often need to be adjusted as time moves forward.

Bernd Kieseier, MD, professor of neurology at the Heinrich-Heine-University in Düsseldorf, Germany, added that the algorithm for treatment decisions has become rather complex.

Once the patient and physician decide to treat the disease, they then have to decide which option is the best, how to monitor if the treatment is working, and when they need to decide that the treatment is suboptimal and a new one should be implemented.

Although nearly all patients in later stages progress similarly, he said that the heterogeneity of the disease makes it difficult to predict the next events in individual patients during the early stages of MS.

“There is an urgent need for better understanding of monitoring…” Kieseier said.

Jeffrey Dunn, MD, FAAN, professor of clinical neurology and division chief of clinical neuroimmunology with the Department of Neurology and Neuroscience at Stanford University Medical Center, and Patricia Coyle, MD, FAAN, professor and director of the MS Comprehensive Care Center at Stony Brook University Medical Center, followed by discussing trial results for 2 drugs: dimethyl fumarate (tecfidera) and peginterferon beta-1a (plegridy).

In the 2-year clinical trial DEFINE, a randomized, double-blind, placebo-controlled, multicenter study, there was a 49% risk reduction of relapse compared with placebo and a 38% reduction in experienced sustained disability progression versus placebo.

Tecfidera also reported an 85% relative reduction in the number of new or newly enlarged T2 lesions, a 72% reduction in the number of new T1 hypointense lesions, and a 90% odds reduction in the number of Gd+ lesions compared with placebo.

Plegridy, an interferon beta for the treatment of patients with relapsing forms of MS, recorded a 36% relative reduction in annualized relapse rate, a 39% risk reduction in proportion of patients with relapses, a 38% risk reduction in proportion of patients with disability progression, a 67% reduction in new or newly enlarging T2 hyperintense lesions, and an 86% reduction in the number of Gd+ lesions.