Current Series: Multiple Sclerosis: A Disease of an Immune System Gone Awry

Fred D. Lublin, MD: Interferon beta-1b was our first approved agent. That was approved 25 years ago in 1993, and we’ve been using it ever since. As is the case for every disease-modifying therapy, there are some people who have responded beautifully to it. I have patients who I started treating in 1993 and 1994 who I continue to treat now, and they’ve done greatly. But not everybody does.

Between the interferons, the higher-dose/higher-frequency interferons tend to do better than lower-dose/lower-frequency interferons. People still argue about this, but I think the data support it. But they’ve been useful. For those in whom they weren’t useful, we’ve been able to move on to other agents. Interferon had a side effect that made people feel like they had the flu, which tended to go away. It involved an injection. If it was subcutaneous, you could get skin reactions. If it was intramuscular, it was a deep injection, but there was some pain associated with it. People actually ended up tolerating it reasonably well. You’d rarely see changes in liver function, but by and large, it was very well tolerated.

Glatiramer acetate was the second class of drug that we had available starting in 1997. The immuno-acid copolymer agent’s efficacy, in some of our studies where we looked at it, was similar to high-dose/high-frequency interferon. It was given through a subcutaneous injection. The feature of glatiramer acetate, besides the fact that we’ve had people who have been on it since 1997 and have done greatly, is that it had really excellent safety. You didn’t have to monitor any blood tests. There was an annoying reaction people would sometimes get right after an injection, where they get flushed and have palpitations. If you didn’t know it was coming, it would scare you. But it would go away in seconds to minutes and nothing ever came of it. Somebody called it a postinjection systemic reaction. But in terms of safety, it was the safest agent and still is the safest agent we have.

This is of some importance because there are a lot of patients who are concerned about safety first more than efficacy. Some would ask, “What is it that I’m putting in my body with these different drugs?” For those people, glatiramer acetate becomes a very good choice.

There’s no role for IVIG [immunoglobulin therapy] in treating multiple sclerosis. There was an initial trial that suggested there could be some benefit, but when it was studied further—both in relapsed and remitting disease, which is what the first trial included, and in secondary-progressive MS—both settings failed. Some of those trials included the same authors who were involved in the first successful trial. It’s not part of our therapeutic armamentarium to use IVIG.