MS: start high-efficacy therapy early to minimize disability

  • He A & al.
  • Lancet Neurol
  • 1 Apr 2020

  • curated by Susan London
  • Clinical Essentials
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Takeaway

  • Among adults with relapsing-remitting multiple sclerosis (MS), initiation of high-efficacy therapy within 2 years of clinical onset, as compared with 4-6 years, reduces disability longer term.

Why this matters

  • According to the treatment escalation paradigm, high-efficacy therapies are usually initiated only after first-line disease-modifying therapies fail.
  • Editorial: evidence points to a "short and early window of therapeutic opportunity," but much remains to be clarified.

Key results

  • High-efficacy therapy started:
    • Early in 51%.
    • Late in 49%.
  • Baseline mean Expanded Disability Status Score (EDSS) scores were almost identical between the early (2.18) and late (2.06) groups.
  • With median follow-up of 7.8 years, mean EDSS score was lower in the early vs the late group:
    • 6 years after disease onset: 2.2 vs 2.9 (P<.0001>
    • 10 years after disease onset: 2.3 vs 3.5 (P<.0001>
  • Difference between groups across 6-10-year follow-up: −0.98 (P<.0001 for time on any disease-modifying therapy.>

Study design

  • Retrospective cohort study, adults with relapsing-remitting MS starting high-efficacy therapy (rituximab, ocrelizumab, mitoxantrone, alemtuzumab, natalizumab):
    • 308 from international MSBase registry.
    • 236 from Swedish MS Registry.
  • Comparison with propensity-score matching: start early (0-2 years) vs late (4-6 years) after clinical disease onset.
  • Main outcome: disability.
  • Funding: National Health and Medical Research Council Australia; MS Society UK.

Limitations

  • Potential residual, unmeasured confounding.
  • Uncertain generalizability.
  • Greater use of certain high-efficacy therapies.