ACTRIMS 2021 | Determining the optimal treatment strategy in MS

We’re in a very exciting era now that we have almost 20 disease modifying therapies for multiple sclerosis and it’s very exciting that there are many choices for MS patients and as well clinicians. And I think it’s important to start thinking about the different types of disease modifying therapies and their different classes, as well as their overall efficacy and side effect profile. And this is how I think about it and how I counsel my patients as we’re walking through treatment options. And so when I first see MS patients, I will look at their overall profile, are they a young patient? Are they an older patient with more established MS? Are they someone who is more likely to have relapses or disease progression? And also what has been their recent history? Have they had a very active inflammatory disease course recently, or have they had a milder disease course or more quiescent disease course?

And so based on that profile, I might sort of choose or start to discuss higher efficacy therapies. And I think in that area, in my mind, higher efficacy therapies include the B-cell antibodies, the S1P modulators and as well natalizumab. Now there are others that may fall into that category that are high efficacy. Alemtuzumab is another one and cladribine and I would say the latter two have slightly higher risk profiles. So this discussion is also a discussion of risk-benefit and overall efficacy versus potential side effects.

And within these different classes of medications, there are some new entrants and particularly in the S1P modulating class, there is ozanimod, which is a new entrant. It is a more selective S1P modulator, and it has a reasonable side effect profile in terms of the cardiac side effects and as well overall similar in terms of the infection risks. So there has been some recent new data and showing some benefit on cognitive outcomes with ozanimod and I think that’s an interesting outcome that is not often studied in clinical trials in MS. And so it’s very nice to have some data showing some benefit for that particular agent.

Another agent that is fairly new is Kesimpta and this is also known as ofatumumab. This is another B-cell antibody, and this is a similar to the prior B-cell antibodies, ocrelizumab and rituximab, has shown very good efficacy overall in suppressing MS disease activity as well as new lesions and overall is well-tolerated. So it’s exciting that we have these new entrants and as well a wide variety of choices for high efficacy treatments.

I think along the other lines in patients who have maybe more established disease who might be in the early progressive stages, then siponimod or Mayzent is certainly something that is recently approved and might be appropriate for late relapsing early secondary progressive patients. And there is again, a good safety profile with Mayzent. So my discussion will tend towards the overall efficacy, the overall safety profile, and then as well mode of administration. And I think it’s important to consider is an MS patient more likely to take an oral drug on a daily basis usually, or would they prefer an injection more infrequently, maybe monthly or every six months and this becomes a lifestyle decision.