Increasing Prevalence of Early DMT Prescription in Radiologically Isolated Syndrome


Researchers from Massachusetts General Hospital found that DMT-treated patients were, on average, younger than untreated patients.

 Ilena George, MD, neurologist, Massachusetts General Hospital

Ilena George, MD

A recent study found that there has been an increasing prevalence of disease-modifying therapy (DMT) treatment in patients with radiologically isolated syndrome (RIS) compared to previously reported literature. 

These data were presented virtually at the Americas Committee for Treatment and Research in Multiple Sclerosis (ACTRIMS) Forum 2021, February 25-27, 2021, by Ilena George, MD, neurologist, Massachusetts General Hospital and colleagues. George et al investigated the prevalence of DMT initiation, choice of DMT, and provider rationales of prescribing DMTs.

“RIS can be considered a pre-symptomatic or early form of multiple sclerosis (MS). Since the condition remains rare, the number of cohorts demonstrating the long-term outcomes in RIS are few. There is equipoise on treating RIS, when to initiate treatment, and with which DMTs,” George and colleagues wrote.

The researchers analyzed data from patients with evidence of demyelinating disease or diagnosis of RIS from the Mass General Brigham Research Patient Data registry seen between May 2005 and September 2020. Patients with a solitary demyelinating lesion and serum autoantibodies were excluded. Altogether, the researchers looked at 89 patients, 11 of which were then excluded due to conversion from RIS to clinically isolated syndrome (CIS) or MS prior to initiation of DMTs. Patients that were followed for at least 2 years were additionally included in a long-term outcome assessment.

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George and colleagues analyzed 49 patients with RIS that had a mean age of 41.0 years at diagnosis, 38 (77.6%) of which were women. Of the patients, 20 (40.8%) were treated with a DMT and 1 was treated with mycophenolate mofetil for uvietis.

The DMT-treated group had a mean age of 37.6 years at diagnosis, younger than the mean age of 44.1 years in the untreated group (P = .03). More than 2 Barkhof criteria were met in 36 patients (73.5%). Across all DMTs, the median treatment duration was 2.67 years. One patient (5%) with RIS treated with DMTs developed CIS during the observation period while on the DMT.

Physicians reported their rationales for prescribing DMTs, the most common of which was magnetic resonance imaging (MRI) change over time including newly gadolinium-enhancing lesions, reported by doctors in 13 cases (65%). Other reasons included clinical suspicion for a high risk of conversion to MS, reported in 6 cases (30%), and/or a high burden of CNS demyelinating disease on MRI, reported in 4 cases (20%).

FIGURE. Disease-Modifying Therapies Prescribed.

FIGURE. Disease-Modifying Therapies Prescribed.

"It is a bit of an open question whether disease activity by itself, meaning, MRI change over time, should be enough to prompt an initiation of a DMT," George told NeurologyLive in an accompanying interview.

First-line DMTs included dimethyl fumarate (n = 7), glatiramer acetate (n = 5), teriflunomide (n = 4), ocrelizumab (n = 2) and fingolimod (n = 1). Second-line agents were initiated in 7 patients with RIS, 5 for DMT tolerability and 2 for MRI activity (FIGURE).

“There is increasing interest in treating the earliest phases of MS, including RIS. In this cohort, over 40% were treated, mainly with low-to-moderate efficacy DMT and primarily after new lesion activity on imaging. Patients had a higher degree of DMT initiation for RIS than previously reported in the literature,” George and colleagues concluded.

For more coverage of ACTRIMS Forum 2021, click here.

George IC, Rice DR, Chibnik L, Mateen FJ. Prevalence and use of disease modifying therapy in radiologically isolated syndrome (RIS): A retrospective study. Presented at ACTRIMS Annual Forum; February 25-27, 2021. Abstract P168
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