Treatment Sequencing in Multiple Sclerosis

Experts in neurology comment on the factors they consider when selecting and sequencing treatments for their patients with multiple sclerosis.

Ahmed Obeidat, MD, PhD: And this brings us to the next question here, sequencing. This is one of the other things that we talk about in the clinic is I sometimes talk to my patients I say, "OK, we'll start you on this medication and if for some reason this wasn't the optimal one for you that maybe we see some breakthrough disease, then the next medication that I have for you is that one." I try to give them the sequence even ahead of time what would be their next choice. How do you approach this in your clinic, in a similar approach, a different approach?

Benjamin Greenberg, MD: Very similar, but with a caveat that again over time this notion of sequencing evolved when we started to realize that certain medications could change the risk or maybe the efficacy of future medications. Now the classic example was the risk of PML with natalizumab. And what was found in studies was preceding immunosuppression would change your risk of a complication on natalizumab later, a PML complication. And we had never thought about drugs that way, that you could have this prolonged risk profile based on what your prior exposures were. We started to think about sequencing in a different way. And now we think about it both from the efficacy perspective, moving from drug A to drug B to try to get better efficacy, and the safety side of things.

Ahmed Obeidat, MD, PhD: And sometimes one of the questions in the clinic that comes up is, when I stop a medication, I want to start another medication, how long I would wait in between? Some people may not wait at all, and some people may actually wait for let's say lymphocytic depletion to come back and maybe a risk of relapse then. It's kind of very tricky.

Benjamin Greenberg, MD: We talked about washout periods for so long. And then in practice, I have to say, I very rarely do any washouts. It's quite normal for me to go from one drug to the other even if cells are still depleted. We have become fearful; I have become fearful of too many backs in therapy and what could happen to our patients.

Hesham Abboud, MD: Especially with the medications that are known to cause rebound activity like natalizumab or S1P modulators. Having a washout period could be dangerous because the patient can have not just the relapse, but a more severe relapse than what they used to have.

Ahmed Obeidat, MD, PhD: These are great insights and I think into talking about sequencing, talking about selection of these modifying therapy.

Transcript Edited for Clarity

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