DMT Selection Considerations in Patients With Multiple Sclerosis

Randall Schapiro, MD, FAAN, and Jeffrey Wilken, PhD, examine the role that cognition and route of administration play in DMT selection in patients with multiple sclerosis.

Ahmed Obeidat, MD, PhD: You mentioned something about selecting DMTs [disease-modifying therapies] based on maybe cognition. If you see early signs of cognition problems, you may be willing to go more with the higher efficacy kind of therapies. Are there any other kind of aspects where cognition affects your medication selection, not only DMTs, but everything else?

Randall Schapiro, MD, FAAN: It could, let’s be practical about things. If somebody’s coming in for an infusion, for example, that person has to show up and they get infused. If they’re taking a shot at home, they have to take the shot at home. And if there’s not a caregiver at home to watch over them, you might want to select an oral agent, but yet it only works if you take them. If it’s an issue with an infusion, you have control over the person, that they are getting it…. That’s a bit of a father to a child type of approach. But I think it’s practical too. Hence, that might influence me in that particular circumstance. Typically, it’s not that much of an issue, but it might come up in a selected individual person.

Ahmed Obeidat, MD, PhD: Dr Wilken, back to the DMT question, we know there are some molecules that may be smaller molecules, some are larger, and there are some that cross to the brain. Do any of those kinds of aspects affect your decision about this patient and what would be the best DMT for them?

Jeffrey Wilken, PhD: Given my position, it’s more that I would be talking to the neurologist if they ask me anything. The biggest question I get from neurologists is a little different from that, and I see it in their notes. Some neurologists will not make decisions about DMTs based on cognition at all. There is no label for that, there is no discussion. But some neurologists specifically say in their notes, “If I see that there’s been a decline in cognition, I’m going to change the DMT.” The typical issue is that they are going to go from a lesser efficacy one to a higher efficacy one. And to be perfectly honest, what molecule that is, is going to depend on what that neurologist is more comfortable using, because often they have the ones that they like the best, and the ones that they don’t like as much, and the ones that are better for not just efficacy, but convenience. Maybe a person doesn’t want to go for infusions, they want to take something oral, or whatever it is. Thus, when it really comes down to it, what they’re asking from me is more of, “Am I looking to change something or not?” They know what they’re going to go to if they’re going to change something.

Randall Schapiro, MD, FAAN: First, you need to find out, are they taking the medicine?

Ahmed Obeidat, MD, PhD: That’s very important.

Randall Schapiro, MD, FAAN: That can be sneaky to find out.

Jeffrey Wilken, PhD: There were some good studies out a few years about compliance and the fact that the noncompliance in MS [multiple sclerosis] medications is so much higher than people realize.

Randall Schapiro, MD, FAAN: Absolutely. Now there’s a new category of immunological medicine that we’re talking about a lot, BTK inhibitors, Bruton tyrosine kinase inhibitors, that work a little differently, but still they’re working on the immune system. Because they’re newer, they are doing more cognitive studies with them because they are looking for sensitivity, ways to show that they are important. I don’t know how all that will pan out.

Transcript Edited for Clarity

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