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Advances in Early Treatment Approaches in Multiple Sclerosis - Episode 16

Original Drugs to Treat MS

Fred D. Lublin, MD: Let me mention our 2 original agents, first is interferon. We have 4 different forms of interferon-beta going back to 1993. Having the grayest hair here, I probably have the most people still on interferon because they’ve done fine on it. We have a lot of people come in, and this started in 2010 when we got our first pill, and it’s continued through now. You say, “Well, we have other choices here.” They say, “Yes, I understand, but I’m doing just fine. I hate my injections but I’m doing just fine, and I’m not going to switch.” And they are doing just fine. And so maybe that will be the group that we ought to start looking at who we could discontinue. On the other hand, I don’t remember the last time I wrote a fresh prescription for interferon. Anyone?

Amit Bar-Or, MD, FRCP: It’s been a while.

Peter A. Calabresi, MD: Exactly what you said. I have a lot of patients who have done really well, the so-called super responders. Maybe their disease has burnt out, but for the most part if they tolerate it well, they can stay on it. If you were to switch over to long-acting Plegridy just for convenience, that seems to be a little bit stronger in some people.

Fred D. Lublin, MD: The other is glatiramer acetate [GA]. That’s a little different situation. I have a bunch of people who are on glatiramer acetate. Again, doing just fine. Don’t want to mess with success. They’re happy to have gone to 3 times a week, and that’s OK. But I also have a population of individuals who come in when we have our first treatment discussion, they ask 1 of 2 things. One is saying, “How long has that drug been around,” when I start talking about drugs. I say, “Well, this one has been out 3 years, this one 5 years, this one has been around 18 years,” that sort of thing. So I already know that that conversation is going to go somewhere different. And there are people who say, “I want the safest thing you have, and I’m worried about what I’m putting in my body.” And those people receive glatiramer acetate prescriptions. Similar experience?

Peter A. Calabresi, MD: Yes, especially for the young women who are considering getting pregnant in a couple of years, it feels like a reasonable place to start.

Patricia K. Coyle, MD: There’s only 1 DMT [disease modifying therapy] that you don’t need to do any blood monitoring for, that’s GA, and it has the best pregnancy exposure data. So those are 2 big issues.

Fred D. Lublin, MD: It’s good for bridging.

Patricia K. Coyle, MD: Yes.

Fred D. Lublin, MD: We also want to say something about teriflunomide. Stephen, do you want to say a little something about teriflunomide?

Stephen C. Krieger, MD: Teriflunomide was an oral agent approved about 8 years ago now for relapsing MS [multiple sclerosis] and for clinically isolated syndrome after a clinically isolated syndrome study. This is a modulator of cell proliferation, so it’s thought of as a more modest immunomodulator and has modest efficacy. At the time, it was felt to have efficacy roughly comparable to the injectable agents that were the standard of care at the time. But I think although we don’t have a lot of new data on this agent, at least not that I have seen, it’s been pretty successful in terms of disease control. They also have some long-term data that have been shown from the study of people who maintain stability on it for quite a number of years.

Unlike with many of our modern medicines, PML [progressive multifocal leukoencephalopathy] has not emerged as a real risk of concern with teriflunomide. And so I think that does distinguish it in some ways from certainly our monoclonals and even from the S1Ps [sphingosine 1-phosphate receptor modulators]. That’s something for patients who have that as a concern, which it’s interesting how well educated and highly aware our patients in MS are. I think people come with very clearly articulated concerns, and that’s one of them. That’s an agent that we’ve had good success with.

I guess the data that we have for teriflunomide in the most recent era now have been teriflunomide as a comparator in trials of new medicines that are being developed. Teriflunomide was the active comparator in the recent clinical trial of ofatumumab, which is a next-generation B-cell depleter. And it was also the active comparator in a trial of a next-generation S1P, ponesimod. And so in both of those trials, teriflunomide was bested from an efficacy perspective by the anti-CD20 and the S1P. But the efficacy has been borne out as basically comparable to what we saw from those pivotal trials roughly a decade ago.