From the Guidelines
The initial treatment for relapsing-remitting multiple sclerosis (RRMS) should involve disease-modifying therapies (DMTs) such as interferon beta medications, glatiramer acetate, teriflunomide, or dimethyl fumarate, with more potent options like fingolimod, natalizumab, or ocrelizumab considered for highly active disease. The choice of initial therapy depends on several factors including disease activity, comorbidities, pregnancy plans, and patient preference regarding administration route 1.
Key Considerations for Initial Treatment
- Disease activity: Patients with highly active disease may require more potent DMTs 1.
- Comorbidities: Certain comorbidities may influence the choice of DMT.
- Pregnancy plans: Some DMTs may not be suitable for patients planning pregnancy.
- Administration route: Patient preference for injectable vs. oral medications should be considered.
Monitoring and Adjustments
Treatment should be accompanied by regular monitoring through clinical evaluations, MRI scans, and laboratory tests to assess efficacy and safety 1. Adjustments to the treatment plan may be necessary based on disease activity and patient response to therapy.
Recent Recommendations
Recent studies and guidelines, such as those from ectrims and the ebmt, provide recommendations for the use of autologous haematopoietic stem cell transplantation (AHSCT) in MS, including its potential use after failure of high-efficacy DMT in aggressive forms of relapsing–remitting MS 1. However, the primary approach for initial treatment remains the use of DMTs, with AHSCT and other intensive therapies considered for specific cases based on disease severity and response to initial therapies.
From the FDA Drug Label
TYSABRI is indicated as monotherapy for the treatment of relapsing forms of multiple sclerosis, to include clinically isolated syndrome, relapsing-remitting disease, and active secondary progressive disease, in adults. The initial treatment for relapsing-remitting multiple sclerosis (RRMS) is monotherapy with a disease-modifying therapy, such as natalizumab (TYSABRI) 2.
- Key points:
- Natalizumab is indicated for the treatment of relapsing forms of MS, including RRMS.
- The recommended dose is 300 mg intravenous infusion over one hour every four weeks.
- Treatment should be initiated and continued under the guidance of a registered prescriber in the MS TOUCH Prescribing Program.
From the Research
Initial Treatment for Relapsing-Remitting Multiple Sclerosis (RRMS)
The initial treatment for RRMS typically involves the use of disease-modifying therapies (DMTs). There are several options available, including:
- Interferon-beta-1b, which has been shown to reduce the frequency and severity of relapses and MRI measures of disease activity 3
- Interferon beta 1a (Rebif®), which has been found to be safe and effective in reducing the number of attacks, disability scale score, and number of lesions at MRI 4
- Glatiramer acetate, which has been compared to interferons-beta in several studies, with similar clinical efficacy at 24 months, but potentially higher relapse rates at 36 months 5
- High-efficacy therapies (HETs), such as ocrelizumab, ofatumumab, natalizumab, alemtuzumab, and cladribine, which may be considered for early treatment to minimize the accumulation of neurological damage 6
Disease-Modifying Therapy (DMT) Options
There are over 18 distinct DMT options approved for the treatment of RRMS, covering 10 mechanisms of action. These options include:
- Interferons-beta (e.g. interferon-beta-1b, interferon beta 1a)
- Glatiramer acetate
- High-efficacy therapies (HETs) (e.g. ocrelizumab, ofatumumab, natalizumab, alemtuzumab, cladribine)
- Other DMTs, such as teriflunomide, dimethyl fumarate, and fingolimod
Safety and Efficacy of DMTs
The safety and efficacy of DMTs can vary depending on the specific therapy and individual patient. Common adverse events associated with DMTs include injection site reactions, asthenia, and an influenza-like symptom complex. The efficacy of DMTs can be measured by clinical outcomes, such as relapse rate and disability progression, as well as MRI outcomes, such as lesion load and disease activity 3, 5, 4. Ocrelizumab has been shown to be effective in patients with RRMS and a suboptimal response to prior DMTs, with 48.1% of patients achieving no evidence of disease activity (NEDA) over 96 weeks 7.