Drs Ahmed Zayed Obeidat and Mark S. Freedman share considerations for individualized therapy for the management of MS.
Ahmed Zayed Obeidat, MD, PhD: When we think about the treatment algorithm, you touched on that a bit here, but do you typically start with highly effective therapies, or some of the lower to moderate effective therapies, or immune modulators? Or do you do a mix of both? We know there are some studies trying to look at this. Let’s touch on the basis of our decisions on how we select a treatment for a patient.
In a clinic, on a weekly basis, we get people who are newly diagnosed, they come into us and they’re like, “Which medication I should I go on?” We always think, “Maybe this class, or maybe this other class, maybe this other class, or maybe highly effective. Maybe you can do well with the lower effective at the beginning. I don’t know.” Sometimes we talk to our patients and have this shared decision-making process. What’s your take on this, and also on the studies that are looking exactly at this question to provide us with answers?
Mark S. Freedman, HBSc, MSc, MD, CSPQ, FAAN, FRCPC: Well, there’s no one-shoe-fits-all for our patients.
Ahmed Zayed Obeidat, MD, PhD: That’s exactly right.
Mark S. Freedman, HBSc, MSc, MD, CSPQ, FAAN, FRCPC: There’s a lot that goes into whether you want to be more aggressive with patients. Let’s talk about the concept of higher efficacy vs lower efficacy therapy. Why are we even having that discussion? If you have a drug that’s highly effective, why would you use anything else? What’s the drawback? Why isn’t everybody throwing out the high efficacy therapies?
Ahmed Zayed Obeidat, MD, PhD: It comes with….
Mark S. Freedman, HBSc, MSc, MD, CSPQ, FAAN, FRCPC: Because it comes with its baggage. There’s stuff that happens with each of these therapies either in the short or long term that increases the risk of an adverse event for those individuals. Some of those are worse than the disease itself if you’re contracting it. If this was candy, ASA [aspirin], or a simple drug like that, we wouldn’t have this discussion. You’d be grabbing at your higher efficacy therapy for everybody.
At University of Ottawa, we’re a big center for bone marrow transplants. We can eliminate the entire immune system, and these patients don’t have any more attacks. They don’t have any more activity whatsoever. Why aren’t we bone marrow transplanting everybody? Obviously, that’s not something you can do on a mass scale, and there are tremendous adverse effects from a bone marrow transplant.
So how do you decide? I think we’re getting better, not so much at being able to predict who’s going to be benign, because that’s a real hard prediction, but there are now ways of picking out the patient who may have a much poorer prognosis. There are so many details we can’t control, like their age, sex, or race. There are some things that just give people a higher propensity for early progression.But other things you need to look at include how the disease has presented itself. Is it just a mild optic neuritis and they recovered, there’s no evidence of any damage, there’s nothing else on the examination, there are a few spots on their brain? Is that somebody who needs the high efficacy therapy? Some people say absolutely, but do they really need it?
If a patient is risk averse and they say, “OK, what about that high efficacy therapy? What’s the long-term adverse effect of this? I’m planning to have babies in the next 2 years; is there going to be an issue with that?” Or “I travel a lot for work, and I need my vaccinations. Is there going to be an issue with that?” Or “I travel and if I need routine blood tests, I don’t have time to do that.” So there’s a lot of stuff that you have to work with your patient on and figure out if this a good fit. If someone can’t comply with everything, you are not going to be able to monitor for safety like you could in others.
Transcript edited for clarity