Which patients can initially be treated with platform DMT?

In a real-world population of Italian patients with relapsing-remitting multiple sclerosis (RRMS), the majority initially received a platform disease-modifying therapy (pDMT) as their first treatment. Some patients continued with pDMT throughout, while others switched to a high-efficacy DMT (heDMT). The study revealed that the majority of patients who followed this treatment pattern experienced poor outcomes, though a subgroup of patients might still benefit from this approach. The authors concluded that pDMT may be considered in young adults with monofocal MS onset, short disease duration, and low disability levels.

The 2 main treatment approaches in RRMS are escalation versus early aggressive treatment. Escalation entails starting with a moderately effective pDMT and switching to a heDMT in case of disease activity, while early aggressive means early application of highly effective DMTs. Dr Ilaria Addazio (University of Florence, Italy) and her group set out to identify the proportion and characteristics of patients who can obtain greater benefits from pDMT [1].

The researchers extracted, from the Italian MS Registry, records of 7,852 patients with RRMS who started a pDMT (interferons, glatiramer acetate, teriflunomide, dimethyl fumarate, or azathioprine) and had follow-up data ≥10 years. Optimal responders to pDMT (patients without 6-month confirmed disability accrual [CDA] who did not switch) were compared with patients remaining on pDMT experiencing a CDA, and patients switching to heDMT.

The mean follow-up was 14.7 years. There were 2,112 (26.9%) optimal responders to pDMT, 2,238 (28.5%) who had a CDA but did not switch, and 3,502 (44.6%) switchers to a heDMT. Optimal responders were relatively younger (OR 0.96; 95% CI 0.95–0.97; P<0.001) and had a shorter disease duration at baseline (OR 0.97; 0.96–0.98; P<0.001). Compared with switchers, optimal responders had:

• Older age (OR 1.03; 1.02–1.04; P<0.001)
• Shorter disease duration at baseline (OR 0.98; 0.97–0.99; P<0.001)
• Lower EDSS at baseline (OR 0.76; 0.72–0.80; P<0.001)
• Monofocal onset (OR 1.26; 1.05–1.51; P=0.011)
• Fewer relapses in the year before baseline (OR 0.92; 0.86–0.97; P=0.004)

A multi-variable analysis of MRI data (n=4,500) showed that, compared with patients with CDA remaining on pDMT, optimal responders had:

• Younger age (OR 0.96; 0.94–0.96; P<0.001)
• More active MRI at baseline (OR 1.23; 1.03–1.46; P<0.001)
• Shorter disease duration at baseline (OR 0.98; 0.97–0.99; P=0.019)

The analysis of MRI and CSF parameters is still ongoing. Thus far, no differences in oligoclonal band positivity between groups had been noted.

1. Addazio I, et al. Optimal responders to platform disease-modifying therapies in the Italian MS Registry. EAN 2023 Annual Meeting, 1–4 July, Budapest, Hungary.

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Posted on 7 September 202325 March 2024