Pharmacotherapy of multiple sclerosis (MS) should always be planned in such a way that therapy may be modified if needed, whether the patient is newly diagnosed or comes to the appointment expressly for a change of medicine. Treatment should also have a tangible objective, the achievement of which should be monitored.
American research scientist Gabriel Pardo gave a presentation at the Biogen Nordic Scientific conference on the flexibility and objectives of MS treatment and on the need to see patients as individuals. The key message was: as MS is a chronic disease, you should also be able to continue treatment with drugs as the disease progresses, and the choice of drug should always be made considering the benefit-risk ratio.
“In addition to choosing the drug therapy for your patient, you also need to plan for any further lines of treatment in case the first drug is not suitable or if the course of disease changes”, Mr. Pardo said with emphasis.
He also explained that when choosing the drug, it is of primary importance to consider the patient’s personal preferences, such as lifestyle and hopes of having a family, the tolerability and safety of the medicine, and the cost and availability of treatment. On the other hand, there is much variation in the progress of MS; thus, expectations of treatment should be realistic, and any factors which may affect the prognosis should be identified.
“You need to choose between escalation strategy, that is, initiating treatment with a low-efficacy drug which may be replaced if needed, and induction strategy, that is, short-term use of a high-efficacy drug at the beginning of the disease. The challenge with induction therapy is that switching from these high-efficacy drugs to another product is often not possible; as the disease progresses, continuity of treatment cannot be guaranteed”, Pardo explained.
“The adaptive nature of the disease, persistence of symptoms and the duration of efficacy of biologic disease-modifying drugs may change. This also requires that pharmacotherapy should remain flexible and switches possible. First-line therapy with a drug which you cannot switch from to another drug is not necessarily advisable.”
As with other drugs, drugs developed for MS are associated with undesirable effects. Adverse effects arising from immunomodulatory and immunosuppressive therapies may persist for months after dose discontinuation; thus, Mr. Pardo emphasised that the benefit-risk-ratio should always be assessed individually for each patient.
“All in all, drugs developed for MS are relatively safe; serious adverse effects such as progressive multifocal leukoencephalopathy (PML) are extremely rare. In general, low-efficacy drugs are somewhat better tolerated and cause a lesser degree of serious adverse effects; however, even high-efficacy drugs are not associated with a significant degree of adverse reactions. For example, the safety of natalizumab varies according to the patient’s JC virus status, and serological testing should be conducted before initiation of pharmacotherapy”, Pardo explained.
While all disease-modifying drugs are effective, not all of them work in everyone; the benefit ratio varies, and individual-level events cannot be predicted. At the same time, all disease-modifying drugs also affect the immune system; the duration of this effect depends on the product.
“The only option is to assess the benefits and risks individually for each patient. The best therapy is the one which best suits the individual patient and prevents disease activity as effectively as possible. After choosing the drug, you need to monitor the patient for clinical and radiological response and evaluate the risks for adverse effects as can be seen from the laboratory results as well as clinically.
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