The conversations taking place on the third day at AAN shifted gears from the day before, placing the focus back on multiple sclerosis and exploring existing treatment strategies for people living with MS in great depth. Specific questions that were brought up include: does stopping immune-modifying treatment in those transitioning into secondary progressive MS affect persistent relapses? How commonly do clinicians switch their patients’ first treatment regimen, and why? What are the effects of specific DMTs on pregnancy outcomes in expectant mothers? Continue reading to learn some of the answers to these questions based on the most recent research findings:
A major question that continues to puzzle neurologists is: in people who go on to develop secondary progressive MS, when does their relapsing-remitting MS end and secondary progressive MS begin? The most likely answer to that question is that there is no tipping point where secondary progressive MS is suddenly switched on, but that instead there is a period of time where the two clinical courses will overlap. Dr. Orhun Kantarci (Mayo Clinic) presented findings from a study of 964 participants in both clinic and “real-world” based cohorts to define the overlapping period in late relapsing-remitting MS and the early progressive phase based on participant age. His team found that for the majority of participants, the overlap age range was between 27 and 47 years. Among those with secondary progressive MS, 14% continued to have post-progression relapses. The team also found that 95% of post-progression relapses take place before the age of 55, and 92% of post-progression relapses were seen within the first five years after what was defined as the onset of progressive MS. These findings provide valuable information that clinicians can use to guide decisions about the use of disease-modifying therapies and switching between therapies in those transitioning into progressive MS.
The next presentation by Dr. Julien Bonenfant (Université de Rennes, France) dovetailed nicely with the one before it, asking the question: can and should immune-modifying treatment be stopped in secondary progressive MS? This is an especially salient question since immune-modifying treatments have generally not demonstrated significant effects on disability progression, leaving many people living with secondary progressive MS wondering whether to continue costly therapies with, in some cases, unpleasant or dangerous side effects. By examining 106 participants living with secondary progressive MS and measuring the impact of treatment discontinuation on annual relapse rates, Dr. Bonenfant showed that relapse rates were stable at 1 and 3 years after discontinuation compared to the three-year period prior to discontinuation. However, the presence of inflammatory lesions in the brain were captured by imaging after discontinuation in certain cases, such as in those individuals with inflammatory activity preceding discontinuation or in those with lower disability. All in all, these data can lead to informed decision-making about treatment discontinuation in people living with secondary progressive MS.
Professor Francesco Saccà (University Federico II, Italy) shared findings from a “real world” study of 1,049 people living with MS in Italy to provide a snapshot of how and why clinicians switch the first treatment regimen to another one in their patients. His team found that in their cohort, nearly half of the participants had their treatment changed within 3 years of therapy. Of note, the primary driver of switching therapies was ineffectiveness of the therapy rather than problems with safety or tolerability. Prof. Saccà included the caveat that as oral disease-modifying therapies have been emerging over the past several years and are becoming increasingly prescribed, these statistics may start to change in the years to come.
A common thread joining three subsequent presentations was the subject of treatment effects on pregnancy-related outcomes in expecting mothers.
- Dr. Sandra Thiel (Ruhr University Bochum, Germany) presented observational data from 445 pregnant women living with MS as part of the German Multiple Sclerosis and Pregnancy Registry that addressed the question: does exposure to the DMT interferon-beta (IFN-beta) during the first trimester of pregnancy affect fetal outcomes? The study found that babies of pregnant women on an IFN-beta regimen during the first trimester did not experience different rates of preterm births or decreased birth weight compared to mothers with MS who weren’t taking IFN-beta, and there was no difference in the rates of spontaneous abortions.
- In contrast, an observational study by Dr. Maria Pia Amato (University of Florence, Italy) found that in her team’s Italian cohort of 465 pregnant mothers living with MS, mothers taking the DMT natalizumab had a higher rate of spontaneous abortions compared to pregnant mothers not taking DMTs (19% versus 7%, respectively).
- Finally, MS Society Transitional Career recipient Dr. Jiwon Oh (University of Toronto) presented pregnancy outcomes from pregnant women with relapsing-remitting MS who had previously participated in alemtuzumab clinical trials. Dr. Oh’s study demonstrated no indication of an increased risk of congenital anomalies or birth defects in babies of mothers who had taken alemtuzumab, nor increased rates of spontaneous abortion. Nonetheless, Dr. Oh maintained that women should use effective contraception during treatment with alemtuzumab and for four months after each course of treatment in accordance with indications on the drug product monograph.