DMT early is better than late but late is better than never

Cocco E, Sardu C, Spinicci G, Musu L, Massa R, Frau J, Lorefice L, Fenu G, Coghe G, Massole S, Maioli MA, Piras R, Melis M, Porcu G, Mamusa E, Carboni N, Contu P, Marrosu MG Influence of treatments in multiple sclerosis disability: A cohort study. Mult Scler. 2014 Sep. pii: 1352458514546788. [Epub ahead of print]

BACKGROUND AND OBJECTIVE: A critical aspect of multiple sclerosis (MS) treatments is understanding the effect of disease-modifying drugs (DMDs) on the long-term risk of disability and whether the effect is related to disability at start of treatment.
METHODS: We performed an observational study on 3060 MS patients. The effect of therapy on progression to Expanded Disability Status Scale (EDSS) 3.0 and 6.0 from onset was analysed in treated vs untreated (UTP) patients.
RESULTS: Compared to UTP, the risks of EDSS 3.0 were 94% and 73% lower in immunomodulant (IMTP-) and immunosuppressant (ISTP-) treated patients, respectively, while the risk of EDSS 6.0 was 86% lower in IMTP. The risk of EDSS 6.0 was, respectively, 91% and 75% lower in 1275 IMTP before and 114 after EDSS 3.0 than in 539 UTP; the risk was higher in IMTP starting therapy after EDSS 3.0 than before (HR = 4.42).
CONCLUSIONS:  DMDs delayed long-term disability in MS patients treated either in the early or, to a lesser extent, in the later phase of the disease. Thus, the window of therapeutic opportunity is relatively extended, assuming that early is better than late treatment, but late is better than never.

Give the Flack that Arie and MD2 have been taking from some of you, first I will say in terms of CoI that none are relevant but we have got grant money from some pharma who produce MS drugs. Start early and they will reap benefits but this study it can work for you too.

I think the conclusions are easy to read and the take home message is simple take a DMT and you do better than if you don’t take a DMT. Take a DMT early and you appear to do better than starting later rather than sooner but that is better than doing nothing. As ever this is an observational study and so lacks the robustness of proper clinical trials with good  follow. Furthrmore it shows that we need to do better with DMT as disability continues in people who are treated. I suspect if we dispense with the low efficacy DMT and repeat this such again in a few years the the outcomes will be much better.

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  • Let me make sure I'm understanding these numbers correctly. The abstract says, "Compared to UTP, the risks of EDSS 3.0 were 94% and 73% lower in immunomodulant (IMTP-) and immunosuppressant (ISTP-) treated patients, respectively."

    I think this means that if 200 people took IMTP and 200 people took nothing, and 100 of the people who took nothing progressed to EDSS 3.0, then only 6 of the people who took IMTP progressed to EDSS 3.0. Am I reading that right?

    • You are correct, but you would not know this from this blog as the goal seems to have everyone on Alemtuzumab or Tysabri.

      Team G has no clue what the longterm effects of thsee "highly effective drugs", but leaving your immune system with a significant reduction in T cells such as what Alemtuzumab does is not a good thing for longterm cancer surveillance.

      Again it goes back to motives since any other neurologist as well as the FDA does not see their point of view.

    • "Any other neurologist … does not see their point of view"? What about Tim Vollmer at the Rocky Mountain MS Center? He's been a vocal supporter of Tysabri and alemtuzumab. In fact, his group gives Tysabri first line to JCV- patients. Then there's Eric Kanter in Florida who has spoken out for alemtuzumab. My neurologist said the FDA didn't approve Alemtuzumab the first time, not because they didn't agree with Team G, but because of political differences and competing pressures from other pharma companies. I'm not saying everyone in the world agrees with Team G, but they aren't alone in their outlook.

    • Every one should have the option of treatment, with the facts in hand you can make the choice what you do or don't do.

      You can look at MS through rose-tinted glasses or not this is your choice. You can stick your head in the sand and hope it all goes away.

      No clue-As to Alemtuzumab there is the cambridge 5 and 12 year follow up.

      As to cancer surveillance please state which papers you are referring in MS and then please contrast this with the affects of other MS drugs or comparable efficacy like natiziuimab, fingolimod. This type of argument sunk movectro and if that was around few would bother with alemtuzumab. I suspect the data is not there for you to make these assertions.

      Any neurologist who can not see the efficacy with alemtuzumab and natailuizmab has problems, however the issue is the risk benefit. As soon as something with similar efficacy and lower side effects come along then these drugs are toast. The clock is ticking

      You question motives— and you seem to imply that we are in pharmas back pocket-wrong…. but what are yours motives, interested MSer or CCSVIer in denial or perhaps a beta interferon/copaxone rep?


    • I am currently on the Cam Thy trial at Addenbrookes, which I'm surprised to find has yet to meet its target recruitment, even after two years. If this is the best available DMT on offer (and I think it may be), then why such reluctance to sign up? fear? Or ignorance? I found about the trial online via the team G blog. None of my local neurology team told me about it. I only wish they had, and much earlier. Wishful thinking is not what you expect from medics, but in my experience it's part of the problem, unfortunately.

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