How Do you Decide on a Disease Modifying Therapy for Multiple Sclerosis?

Written by Revere (Rip) Kinkel MD
Director of the Multiple Sclerosis Program
Professor of Clinical Neurosciences
University of California San Diego


I am afraid this blog has the potential to be overly controversial, so I will tread softly with my comments. Here we go:

Patients often exclaim (more often it’s a complaint) during our initial encounter that their prior physician sent them home with 3 or 4 drug company pamphlets to read with instructions to call the office back and let them know which treatment they prefer.  Other patients tell me that their prior physician gave them no choice and recommended a specific treatment.

These approaches represent two ends of a spectrum that I find lacking.  Rarely, do I hear of patients being informed of the pros and cons of available therapies, and even more rarely do I hear of any prior discussion of the short and long term goals of therapy.  While it is true that we have very little useful comparative effectiveness data to help patients and physicians choose a therapy, there is data available to guide us in these decisions.

So without comparing drugs let’s consider some of the factors that should go into the decision making process.  All of these factors should be considered in your selection of treatment

1. Where are you in the course of the illness? Are you a patient newly diagnosed with no evident impairment, mild disease activity, and no prior treatments, or are you a patient many years into the disease with obvious disability and often with many prior treatment trials?  The former patient is a good candidate for a platform therapy (interferon or copaxone) whereas this may not be true for the latter patient.
2. Do you have a variant of MS that may not respond to certain therapies or at a minimum may require additional monitoring? For instance, some patients with Neuromyelitis optica receive an inaccurate diagnose of MS;  these patients will not respond well to standard injectable therapies. Similarly, there is some evidence that African Americans with MS may not respond well to interferons. Although this evidence is not strong, it should at least be considered in therapeutic decisions.
3. Do you have any comorbid conditions or risk factors that may impact treatment? For instance, a patient with Type II diabetes is at much higher risk for complications from both MS and from treatments like corticosteroids.  I tend to treat these patients earlier with highly active MS therapies (Tysabri) to reduce the combined risk of complications from both conditions. More obvious examples include the patient with cardiovascular risk factors not being a good candidate for fingolimod (Gilenya) or the patient with chronic irritable bowel syndrome or significant gastritis not being the best candidate for dimethylfumarate (Tecfidera). Patients with frequent migraine or headache disorders can find interferon treatment challenging.
   
4. Are you on other medications that may interact with one of the MS treatments? While this problem is less common with currently available treatments there are some examples: for instance, fingolimod (Gilenya) should not be used in patients on certain anti-arrhythmic therapy.
5. Do you have any plans for pregnancy in the near future, usually the next 2-3 years? If so, your MS specialist will need to create an appropriate treatment plan to take this into account. For instance, treatment with teriflunomide (Aubagio) would not be the best choice in this circumstance.
6. Do you have injection phobia?
7. Are there any unique lifestyle issues such as the need to travel frequently? Daily or every other day injections can be a challenge in this circumstance.
8. In the near future we will be using more biomarkers to help with treatment decisions. For now, the most common biomarkers for both therapy selection and monitoring include anti-interferon neutralizing antibodies in interferon treated patients, anti JCV antibodies in patients considering Tysabri and anti-Tysabri antibodies in Tysabri treatment patients.
9. Lastly, we cannot underestimate the role of insurance companies in treatment decisions for right or wrong reasons. Many plans now require a step approach to therapy insisting that a patient fail one or more injectable therapies before an oral therapy or highly active therapy can be considered. You must develop a plan with your MS specialist to deal with these restrictions in a way that does not interfere with your ability to get the best treatment for your situation.

Next, you must consider the goals of therapy and have these clearly in mind before you begin treatment. Otherwise you will never know when to consider altering your therapy in the future. Goals will also depend on where you are in the course of the disease and your prior response to therapy. With some therapies there is good evidence to support switching treatment if there is continued MRI activity 6 to 12 months after starting treatment.  This is particularly well documented for interferon therapy. Of course this is only useful in monitoring patients early in the course of the disease. Later in the disease course, it is less common to see new MRI lesions or relapses even with ineffective treatment. For these patients, an appropriate goal may include maintaining the ability to walk a certain way for a certain interval of time or preventing the spread of the disease from the legs to the hands. These types of goals will also help you seek out the most appropriate rehabilitative therapies to complement pharmacological management.

I hope these thoughts help you in the process of considering different treatment choices. The issues are far more numerous and nuanced than I can detail in this blog, but this framework will allow you to carry out a more thoughtful decision making process with your family and physician.


Revere (Rip) Kinkel MD
Director of the Multiple Sclerosis Program
Professor of Clinical Neurosciences
University of California San Diego

PLEASE NOTE:  The medical information on this site is provided as an information resource only, and is not to be used or relied on for any diagnostic or treatment purposes. This information does not create any patient-physician relationship, and should not be used as a substitute for professional diagnosis and treatment.  Please consult your health care provider before making any healthcare decisions or for guidance about a specific medical condition.