Oral Therapy Options for Relapsing-Remitting Multiple Sclerosis - Episode 12

RRMS: Patient Prognosis and Treatment Planning

The patient factors and other variables that impact first-line treatment decisions in relapsing-remitting multiple sclerosis.

Jennifer Graves, MD, PhD, MAS: What do you think the impact is of that initial decision? You make a first drug choice at the beginning of their journey with MS [multiple sclerosis]. What’s the impact of what you pick first on what you might be able to pick down the road? Do you take that into consideration? What do you think the impact is of that first decision?

Suma Shah, MD: I don’t think we have any good answers, but there’s [an impact]. There’s a compounding of immunosuppression that happens with time. Our ability to take surveillance serologies, like the JC virus titer, into consideration with good confidence goes out the window as we start to compound different types of prior immunosuppression. All of that to say as we start to enter into an individual’s compounding of different treatments, we end up in a bit of the land of unknown.

Gabrielle Macaron, MD: It’s also worth mentioning the approach that we choose. If you consider the escalation approach, then we should probably expect switching people, along with switching if they have breakthrough disease. If we consider the early high-efficacy approach, then we’d probably consider that this choice is going to stick with the patient for a longer time.

Suma Shah, MD: That’s a great point.

Jennifer Graves, MD, PhD, MAS: Dr Shah, you brought up JC virus and PML [progressive multifocal leukoencephalopathy]. Do you guys want to reflect on whether you take PML risk into consideration with any of the MS oral drugs?

Suma Shah, MD: Not strongly. It’s 1 that I use as a prescreening laboratory test if we’re having the first initial discussion about the patient’s treatment. However, when it comes to determining oral therapies, that’s not how the stratified titer was interpreted or meant to be interpreted. It was looked specifically in patients who were treatment-naïve who didn’t have prior immunosuppression the way we interpret it in patients who were being treated with natalizumab. That makes my ability to use a JC virus titer for directing clinical decisions for orals pretty limited.

Gabrielle Macaron, MD: I agree 100%.

Jennifer Graves, MD, PhD, MAS: Thank you for watching this NeurologyLive® Peer Exchange. If you enjoyed the content, please subscribe to our e-newsletters to receive upcoming Peer Exchanges and other great content right in your in-box.

Transcript edited for clarity.