New results indicate that early intensive treatment (EIT) strategy is more effective than escalation to higher-efficacy disease-modifying therapy (ESC) strategy in controlling disability progression over time.
The most important goal of multiple sclerosis (MS) therapy is the prevention of long-term disability accumulation. Choosing the MS therapy has become increasingly complex, due to the difficulties in weighing the risk/benefit ratio of several different available disease-modifying therapies (DMTs). To date, except for individuals expressing poor clinical and radiological features at baseline, the most applied treatment algorithm for early naïve MS is based on an escalation strategy. Whether patients initiating therapy with high-efficacy DMTs derive a greater long-term benefit on disability accumulation than those who start with moderate-efficacy agents remains a matter of debate. Early initiation of highly effective therapy in RRMS may provide more benefit than an escalation approach in decreasing the risk of developing secondary progression and disability accrual, at least in a medium-term of 5–6 years of follow-up.
A recent study evaluated the disability trajectories in relapsing–remitting multiple sclerosis (RRMS) patients treated with an early intensive treatment (EIT) or with a moderate-efficacy treatment followed by escalation to higher-efficacy disease modifying therapy (ESC).
In this investigation RRMS patients with ⩾5-year follow-up and ⩾3 visits after disease modifying therapy (DMT) start were selected from the Italian MS Registry. EIT group included patients who received as first DMT fingolimod, natalizumab, mitoxantrone, alemtuzumab, ocrelizumab, cladribine. ESC group patients received the high efficacy DMT after ⩾1 year of glatiramer acetate, interferons, azathioprine, teriflunomide or dimethylfumarate treatment. Patients were 1:1 propensity score (PS) matched for characteristics at the first DMT. The disability trajectories were evaluated by applying a longitudinal model for repeated measures. The effect of early versus late start of high-efficacy DMT was assessed by the mean annual Expanded Disability Status Scale (EDSS) changes compared with baseline values (delta-EDSS) in EIT and ESC groups.
The study cohort included 2702 RRMS patients. The PS matching procedure produced 363 pairs, followed for a median (interquartile range) of 8.5 (6.5–11.7) years. Mean annual delta-EDSS values were all significantly (p < 0.02) higher in the ESC group compared with the EIT group. In particular, the mean delta-EDSS differences between the two groups tended to increase from 0.1 (0.01–0.19, p = 0.03) at 1 year to 0.30 (0.07–0.53, p = 0.009) at 5 years and to 0.67 (0.31–1.03, p = 0.0003) at 10 years.
The results of this real-world study indicate that the long-term disability trajectories are more favorable with an EIT strategy than with moderate-efficacy DMTs followed by escalation to high-efficacy DMTs. Although further studies are necessary, especially to establish the long-term safety risks of the EIT approach, these findings may drive the treatment decisions of physicians, in particular in the cases of naïve patients with poor prognosis factors at the onset of disease.
Source: Iaffaldano P, Lucisano G, Caputo F, et al. Long-term disability trajectories in relapsing multiple sclerosis patients treated with early intensive or escalation treatment strategies. Therapeutic Advances in Neurological Disorders. January 2021. doi:10.1177/17562864211019574
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