With improving medications and MRI technologies doctors are now likely to change medications at smaller hints of disease activity.
In the last decade there has been a change in the way MS is being treated. The advent of new highly effective therapies for MS means that doctors are much more likely to switch and change treatments in response to new symptoms. A recent study carried out on medical records stored in the world’s largest MS clinical database, MSBase, showed that they are tolerating less and less disease activity and are changing medications for MS more than ever before.
The new medications now give doctors treatment options which allow them to select the best therapy for each individual at the time and thus ensure the best outcomes are reached. This is a challenge because not everyone will respond to the same medication in the same way and unfortunately there is no early warning system to predict which patient will respond to which medication. The other challenge neurologists face is knowing when to switch medications.
Traditionally, when there was limited number of medications, there wasn’t the possibility to switch therapies but as more and more treatments came along neurologists began to have options. Originally most would try a different medication if there was a clinical relapse but now with even more options and more effective options, neurologists are trying to reduce disease activity even further. Neurologists are now aiming for not only stopping relapses but also stopping magnetic resonance imaging (MRI) activity, and the goal of treatment has become what is called ‘no evidence of disease activity’ (NEDA). NEDA is defined as the name suggests based on the absence of clinical relapses and any MRI activity.
A group of international scientists have been examining with what and how MS neurologists are treating relapsing remitting MS, and at what level of disease activity they switch a person’s medication. They looked at 4332 people with MS, their MRIs and what treatment changes were made if there was a lesion identified that didn’t lead to any symptoms – the so called “silent lesions”.
There results were recently published in the Multiple Sclerosis Journal and they show that treatment management in relapsing remitting MS relies heavily on MRI monitoring, and that the identification of even one new T2 lesion in the brain that didn’t causes a symptom led to a treatment change about 26% of cases. This increased to 50% for those people with more than 6 new T2 lesions on the brain. T2 lesions are generally considered to be older and less active lesions. If a person had a more active or a T1 lesion they were twice as likely to have their medication switched as compared to a T2 lesion. Also the results show that if a person was on an older style medication (such as an injectable medication) they were more likely to be switched following a silent brain lesion as detected by MRI.
It is important to note that not every country in the world has affordable access to all the MS medications available, and this may making switching difficult in some cases.
Overall this study shows that MS specialists are increasingly relying on MRI alone to make treatment decisions, and that they are tolerating less and less disease activity, and will even switch people’s medication if there is one silent lesion in the brain. This highlights the importance of MRI in treatment decisions and the need for regular scans, even in the absence of new symptoms. It clearly demonstrates the changing clinical management of MS, and that the availability of the newer highly effective medications have allowed the goalposts to shift in this very dynamic treatment landscape, which is likely to have a huge positive effect on the long-term outcomes of people with relapsing remitting MS.