How and when to make a timely switch to high-efficacy DMT

For a variety of reasons, relapsing-remitting MS (RRMS) patients together with their neurologist can decide on starting treatment with a low- or moderate-efficacy therapy. Such an escalation approach continues to be a viable paradigm, in view of varying disease severity, medication safety, and patient preference.

Many RRMS patients choose to start with a disease-modifying therapy (DMT) that has low or moderate efficacy, to then escalate this therapy when necessary, as opposed to starting with an early, intensive therapy. According to Dr Dalia Rotstein (University of Toronto, Canada), such an escalation approach can be considered due to favourable prognostic factors, long-term safety concerns, patient preference (in terms of safety and route of administration), access, or associated cost [1]. She emphasised that treatment response should consequently be assessed early. “MS is a highly heterogeneous disease which is largely unpredictable, especially early on. So, the first 1 or 2 years of therapy can provide valuable information to determine what treatment intensity is required in the long term.” In these first 2 years, the patient should be closely monitored for relapses, MRI activity, and disability progression, while also considering levels of neurofilament light (NfL).

No randomised-controlled trials exist to date to guide treatment switches. When considering a switch, the neurologist should take the time to treatment effect (varying from 3–6 months) into account, and then obtain a re-baseline MRI. Generally in guidelines, 1 or more relapses are usually seen as a cause for concern, as well as a confirmed Expanded Disability Status Scale (EDSS)-progression of at least 1 point. More controversy exists regarding MRI, but anywhere between 1–3 new T2 lesions should be a reason to consider a switch.

To avoid delays in escalating therapy, vaccination in advance (especially in the COVID-19 era) is important. According to Dr Rotstein, the washout period should be minimised. In recent studies, prolonged washout periods have been associated with an elevated risk of new disease activity, particularly after terminating fingolimod treatment [2]. She concluded that early aggressive therapy (the “hit-hard-and-early” concept) may gain popularity, but the escalation approach continues to be a viable paradigm, in view of varying disease severity, medication safety, and patient preference.

1. Rotstein DL. How to make a timely switch to high efficacy DMT. Abstract O006, ECTRIMS 2022, 26–28 October, Amsterdam, the Netherlands.
2. Alroughani  R, et al. Mult Scler Relat Disord. 2019;34:9–13.

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Posted on 20 December 202225 March 2024