Melbourne, Australia—Balancing risk versus safety of therapies to reduce flare-ups can be especially difficult in patients with secondary progressive multiple sclerosis (SPMS).

A new article in Neurology offers some advice on finding treatments for advanced MS, especially since about half of relapsing-remitting MS patients eventually transition to the secondary progressive form. Australian authors from the University of Melbourne suggest that, while potent disease-modifying drugs are more effective in reducing flare-ups in SPMS than those safer and less potent, one does not appear to stem progression more than the other.

“Multiple sclerosis is a complicated disease to treat and must be closely monitored as it is managed with various medications, some of which can have serious side effects,” explained study author Tomas Kalincik, MD, PhD, of the University of Melbourne. “High-efficacy medications are prescribed in early multiple sclerosis to more aggressively treat the disease and have been found to more effectively prevent flare-ups and modify progression, but less is known about how effective these therapies may be later when relapsing-remitting MS transitions to secondary progressive MS.”

To compare the clinical effectiveness of high- and low-efficacy treatments in patients with recently active and inactive SPMS , researchers focused on 1,000 patients with the condition. They followed the participants for a decade to determine if they relapsed and/or became more disabled over time.

Patients were divided into two groups: Those treated with high-efficacy (natalizumab, alemtuzumab, mitoxantrone, ocrelizumab, rituximab, cladribine, fingolimod) or low-efficacy (interferon beta, glatiramer acetate, teriflunomide) therapies after SPMS onset. Data was gathered from MSBase and OFSEP, two large observational cohorts.

The study team also estimated therapeutic lag for each patient based on their demographic and clinical characteristics. Ultimately, 1,000 patients were included in the primary analysis.

Results indicate that patients with active SPMS treated with high-efficacy therapy experienced less frequent relapses than those on low-efficacy therapy (hazard ratio [HR] 0.7, P = .006). On the other hand, for patients with inactive SPMS, no evidence of a difference in relapse frequency between groups (HR = 0.8, P = .39) or risk of disability progression was determined.

“In treated patients with SPMS, high-efficacy therapy is superior to low-efficacy therapy in reducing relapses in patients with active, but not those with inactive, SPMS,” the authors point out. “However, more potent therapies do not offer an advantage in reducing disability progression in this patient group.”

“Our study finding that high-efficacy therapies are superior to low-efficacy therapies only in reducing relapses in people with active secondary progressive MS provides valuable guidance for neurologists when choosing the most effective therapies for people with this form of MS,” Dr. Kalincik explained. “When the goal is to alleviate ongoing relapse activity, more potent therapy is justified. But when the goal is to limit disability progression in secondary progressive MS, both types of drugs show comparable effectiveness.”

Dr. Kalincik adds that individual therapies might have different effects on symptoms and disability and that those be examined separately in future research.

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