Happy New Year and don’t forget to take your tablets!

Mult Scler Relat Disord. 2018 Dec 19;28:104-108. doi: 10.1016/j.msard.2018.12.025. [Epub ahead of print]

Adherence to oral disease-modifying therapy in multiple sclerosis patients: A systematic review.


  • Fingolimod has the longest time to discontinuation when compared to dimethyl fumarate and teriflunomide.
  • Fingolimod may be better tolerated than dimethyl fumarate and teriflunomide.
  • There were no significant differences in discontinuation rates reported between fingolimod, dimethyl fumarate and teriflunomodie.
  • The most common reasons for discontinuation of oral DMTs were adverse reactions, intolerance, and disease activity.

Medicines may just be what the doctor ordered, but few including myself ever adhere to this advice religiously. The writing on the label isn’t a typographical error and if you’re not taking this, ask yourself, are you in fact on treatment? Side effects in medicines are guaranteed (believe it or not), and not a rare occurrence as the manufacturers would have you believe.

But how good or bad are our current MS therapies? First came the injectables, poorly tolerated by most if not all – I had patients who would rather face MS than take them (not a great selling point). Wind forward a couple of years and there were the first oral treatments (fingolimod, teriflunomide, dimethyl fumarate); it seemed someone was listening to us finally. We soon learnt, that they were good, but not that good. Where we now stand in the RRMS landscape is lady bountiful, and adherence becomes a major factor for treatment selection.

So how do our oral therapies fare in terms of adherence? After searching through 1921 articles, the authors have found 6 articles that were deemed useful to look at this.

On balance, fingolimod has better tolerance than either teriflunomide or dimethyl fumarate. But, what I found shocking was that even at 12 months persistence with treatment was 74% for fingolimod, 56% for dimethyl fumarate, and 50% for teriflunomide! What is going on here? I suppose it’s the usual suspects; and these seem to range from side effects, disease activity, and disability progression. Factors that are unlikely to change in the future.
And think about this, given that a certain percentage of patients are not on treatment, how do we assess whether a treatment is working or not? Surely, the solution here is to use infusion therapies at the outset or throughout, with fewer disruptions to one’s routine as seemingly possible? I leave that for you to ponder on this New Year’s day.

Have a great 2019 all, I have a good feeling about this year…

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Neuro Doc Gnanapavan

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