CONy 2022 | Using DMTs beyond patients with active MS
Xavier Montalban, MD, PhD, MBA, Vall d’Hebron University Hospital, Barcelona, Spain, discusses administering disease modifying therapies (DMTs) for patients who have multiple sclerosis (MS) and may not have MRI activity. Current therapies such as siponimod for secondary progressive MS (SPMS) and ocrelizumab for primary progressive MS (PPMS) are currently only prescribed for patients with progressive or relapsed disease. However, relapses can be difficult to identify and can be missed, especially when monitoring can be sporadic. This interview was conducted during the 2022 World Congress on Controversies in Neurology (CONy) meeting.
Transcript (edited for clarity)
Well remember that that was a debate. That was an academical debate and I had the worst part of the debate, of course, the most difficult part to defend. But yeah, it is clear that siponimod and anti-CD20, they do work much better in patients who have active disease. There is no doubt about it, but there are a number of aspects. One is that in many occasions, to identify relapses is not an easy task...
Well remember that that was a debate. That was an academical debate and I had the worst part of the debate, of course, the most difficult part to defend. But yeah, it is clear that siponimod and anti-CD20, they do work much better in patients who have active disease. There is no doubt about it, but there are a number of aspects. One is that in many occasions, to identify relapses is not an easy task. So sometimes you think you are talking about relapses and they are just fluctuations on one hand or the other way around. So you just miss a number of relapses because you see the patient every, I don’t know, six months or every year, and you can miss some relapses on one hand.
On the other hand, the MRI gives you a picture at specific time point, but nothing for the last 12 months. So perhaps you are missing as well GAD lesions. So the point is that in a number of patients who, you are not able to identify clear relapses or you perform MRI, and there is no GAD lesions, if the patient is young enough, and if the patient is progressing rapidly, I think you should make a try and you should try anti-CD20, or siponimod.
The European guidelines, they’re very clear when you have a patient with progressive disease and inflammatory activity, no doubt about that. And they recommend for patients with SPMS, with evidence of inflammatory activity, which means relapses and/or MRI activity, offer treatment with Siponimod. But also for patients with secondary progressive MS without evidence of inflammatory activity, but particularly in young patients and those in whom the progression has started recently, consider treatment with siponimod or anti-CD20 as well.
So you should discuss with the patient the pros and cons, you have to talk about the expectations, et cetera, but it’s an option. Even for the ECTRIMS and European Academy of Neurology guidelines, you have a young patient with a rapid progressive disease, even without clear inflammatory activity, you should offer those medications. And for PPMS, for instance, the European guidelines say that consider ocrelizumab for patients with primary progressive MS, particularly, not only in early and active and clinically and radiologically disease.
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Disclosures
Dr Montalban has received speaking honoraria and/or travel expenses for participation in scientific meetings, and/or has been a steering committee member of clinical trials and/or participated in advisory boards of clinical trials in the past years with Actelion, Alexion, Bayer, Biogen, Bristol-Myers Squibb/Celgene, EMD Serono, Genzyme, Hoffmann-La Roche, Immunic, Janssen Pharmaceuticals, Medday, Merck, Mylan, Nervgen, Novartis, Sanofi-Genzyme, Teva Pharmaceutical, TG Therapeutics, Excemed, MSIF and NMSS.
