If you have to switch make sure it is effective

Treatment escalation leads to fewer relapses compared with switching to another moderately effective therapy. Chalmer TA, Kalincik T, Laursen B, Sorensen PS, Magyari M; Members of Danish Multiple Sclerosis Group.J Neurol. 2018. doi: 10.1007/s00415-018-9126-y.

BACKGROUND Patients with multiple sclerosis who experience disease breakthrough often switch disease-modifying therapy (DMT).
OBJECTIVE: To compare treatment effectiveness of switch to highly effective DMT (heDMT) with switch to moderately effective DMT (meDMT) for patients who switch due to disease breakthrough defined as at least one relapse within 12 months of their treatment switch.
METHODS:We retrieved data from The Danish Multiple Sclerosis Registry on all relapsing-remitting MS patients with expanded disability status scale (EDSS) less than 6 who experienced disease breakthrough. We used propensity score matching to compare annualized relapse rates (ARRs), time to first confirmed relapse, time to first confirmed EDSS worsening and time to first confirmed EDSS improvement.
RESULTS: Each matched group comprised 404 patients. Median follow-up time was 3.2 years [interquartile range (IQR) 1.7-5.8]. ARRs were 0.22 (0.19-0.27) with heDMT and 0.32 (IQR 0.28-0.37) with meDMT; relapse rate ratio was 0.70 (95% CI 0.56-0.86; p = 0.001). Escalation to heDMT reduced the hazard of reaching a first relapse (HR 0.65; 95% CI 0.53-0.80; p < 0.001). We found no evidence of delayed disability worsening (HR 0.83; 95% CI 0.62-1.10; p = 0.20) and weak evidence of disability improvement (HR 1.33; 95% CI 1.00-1.76; p = 0.05) with heDMT.
CONCLUSION: Switching to heDMT is associated with reduced ARR and delay of first relapse compared with switching to meDMT. Patients on DMT who experience relapses should escalate therapy to heDMT.Patients with multiple sclerosis who experience disease breakthrough often switch disease-modifying therapy (DMT).

This study says if you are switching make sure you switch to a higher efficacy alternative, Simple. Going to low efficacy drug

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    • That question is also on my mind. What do you do when you hit the top with one high efficacy drug say Tysabri And you experience another relapse? Do you switch to another high efficacy drug such as Alemtuzumab or HSCT? But then again, what happens when you are on Alemtuzumab; is it safe to continue to use another high efficacy drug since Alemtuzumab remains in your system?

  • Is it better,therefore, to start with lower efficacy drugs and have scope to switch to a higher efficacy drug. Or start more aggressively from the beginning?

    • What is gone is gone, the ocrelizumab extension study does it for me. The people acquire disability on beta interferon compared to ocrelizumab, when they switch the difference of loss is maintained over the next three years.

      You know me I am biased and don't like the CRAB drugs. Drugs with a solid biology do better go to the regulator websites and they haven't got a clue how they work and for many they don't.
      COI: multiple

      There are two trials planned that will compare alemtuzumab and HSCT in a head to head and another of highly effective verses the escalation approach using standard of care. We will not be doing this trial as we don't have equipoise as we don't use enough of these.

      I would love to draw a UK map of the prescribers of the CRAB drugs, it will show up the risk-averse neuros. Freedom of information requests anyone.

      I know pharma do this as we have had such requested..Slip me the data and I've draw a map, it would be interesting would'nt it.

  • Unfortunately, I don't understand the end of the article … "Going to low efficacy drug …" and then ? Is there something missing?

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