As you might have captured in one of my preceding blog posts, I’m relatively new to the MS research blog. There is a logical explanation for this: I only started to work at BartsMS in November 2019. With the purpose of converting me in an MS-ologist, I was one of the fortunate people to receive a clinical fellowship grant from the European MS association ‘ECTRIMS’.
The preceding ten months, I had the privilege to participate in the MS clinics of the BartsMS team. This has resulted in many new insights when it comes to the mode of action of the available disease-modifying therapies (= B versus T cells), treatment strategies (= escalation versus induction approach), COVID-19 readiness and – partially against my will – NHS England eligibility criteria for MS disease-modifying treatments. Although I’m happy to be aware of all these important treatment aspects, I must admit that they play the second fiddle when I offer therapies to pwMS.
As I have been able to judge from the front line (read: behind my laptop camera as all our clinics are remote nowadays), people with MS in the first place want to leave the ‘kingdom of the sick’ and some drugs are clearly better at this than others. To summarize my impressions, I have made a radar chart of all currently available therapies:
The axes of the chart range from 0 to 1, with 0 being a very low score and 1 being an exceptionally high score.
A little word on the categories I selected:
- Family planning: The majority of people with MS are women of fertile age. Therefore, treatments that you may continue while trying to conceive and/or during pregnancy as well as treatments that you only take temporarily and allow carefree family planning afterwards score high in this category. One of the most daunting MS relapses are the ones that happen in the three months after a woman with MS has given birth. Treatments that protect women with MS during this vulnerable period in life equally score high.
- Side effects: Side effects, especially when causing daily discomfort, unwillingly remind and confront pwMS every day of having the disease. This is especially difficult to tolerate for pwMS as they often feel perfectly fine between relapses. Treatments that have this kind of ubiquitous daily presence will score low in this category.
- Vaccination: Especially relevant during COVID-19 times and for people with MS that are already longing to venture around the world again. Treatments that allow you to have conjugate and live vaccines during or after completing the full treatment course score high in this category. FYI: Live vaccines are necessary to travel to many countries in Africa and South America.
- Convenience: Drugs that you need to take or inject on a daily basis score low while treatments that you need only once every couple of months/years score high.
- Efficacy: The ability of a drug to avoid new MS relapses and thus the interference of such unpredictable symptoms with daily life, work and leisure is priceless. Drugs that are more effective at controlling disease activity will score higher in this category.
As you might notice when looking carefully at my graph, there is an important treatment paradox in the MS landscape. Treatments with lower efficacies in terms of reducing relapses which are typically grouped as ‘first-line drugs’ require a higher tolerance for side effects of the pwMS that are using them. Conversely, treatments that are considered highly effective (e.g. Tysabri, Mavenclad, Ocrevus) have a much lower burden to pwMS than what would be expected from their potential to control disease activity.
Obviously, this graph is a simplification of treatment decisions in MS and many more aspects such as for example the risk of progressive multifocal leukoencephalopathy need to be taken into account. However, I feel these patient-centred aspects of treatment strategies are underrepresented in discussions on this topic and especially in the current NHS England eligibility criteria for disease modifying drugs.
In conclusion, instead of converting the MS treatment landscape into a war zone of conservatives versus liberals, hawks versus doves and doers versus thinkers, the real question that we as neurologists need to discuss is how we use our treatment arsenal to enable pwMS making peace with their disease.