The answer has to be Neuros…So what’s the Question? You don’t want to know!…Early verses late CD20 depletion.


Early verses late initiation of high efficacy treatment is again seen to be a better option (see below)…It says to me get on a presumed high-efficacy drug as quick as possible….Surely such a no brainer. Why are we even discussing this?

Why is pharma able to do trials against agents that they know are going to be weaker than their new agent?

The answer has to be neuros as they go along with it, but its not their brains they are allowing to be shredded.

I often wonder why platform agents are still on the agenda? (Yes they work for some people and some people will hate me for saying this because they are on platform agents).

However, they are being used routinely…big time. I would say probably the escalation low to high efficacy agents is probably the norm in the UK. Indeed, in a limited survey of UK Neuros it says…percentage of patients treated with high efficacy early or escalation approaches were 42.1% and 58.3%. So about 60% not on high efficacy agents in the limited sample in the UK, Does that shock you?

Is that a 60 low or a 60 high

Is your neurologist a “60% low” are there any neuros who are 60% high…I know there are some, but who are they? We would need to see the prescriptions of the different NHS trusts to see this….Will this ever be shown? This is what the Patient advocate groups should be reporting….Yep it will make me unpopular for saying this. Anyway back to the post.

Treat early and effectively. I would say “The evidence is there how much more do we want? We need to start treating soon as possible.

You can’t get much quicker than ATTACK MS so well done to ProfK for getting it off the ground.

The aim is to get people on natalizumab as soon as possible after the first attack. Why natalizumab…it works quickly so it will stop the next attack whilst the diagnostic work up occurs, Importantly it gives the person some breathing space with their potential diagnosis and allows them to get up to speed with all the big array of drugs on potential offer. Natalizumab it is relatively safe and if diagnosis is wrong (unlikely), people could stop without too many consquences. Likewise, it will be easy to switch once people have made their choice if they get MS diagnosis and have to decide what treatment they want…Hopefully not into the 60% low zone.

One of the aims of the project is to recruit people to the trial and offer them natalizumab and this is the concern. Because if we are still having this debate with neurologists specialised in MS about not using high-efficacy treatment….what about A&E doctors that are not even neurologists? ECTRIMS may not be on their bucket list. Are they going to say “hey we can get you on treatment ASAP”….When they were at Med School the platform agents may have been taught and natalizumab had a different approval indication. Are they going to be valiant and recruit people to the study…Let’s hope so.

Anyway what started my rant. Oh yes…..

Vudumula U, Patidar M, Gudala K, Karpf E, Adlard N. Evaluating the impact of early vs delayed ofatumumab initiation and estimating the long-term outcomes of ofatumumab vs teriflunomide in relapsing multiple sclerosis patients in Spain. J Med Econ. 2022 Dec 6:1-27. 

Objectives To evaluate the impact of early (at first-line) vs delayed (3-year delay) ofatumumab initiation and long-term clinical, societal, and economic outcomes of ofatumumab vs teriflunomide in relapsing multiple sclerosis (RMS) patients from a Spanish societal perspective.

Methods Inputs were sourced from ASCLEPIOS I and II trials and published literature.

Results At the end of 10 years, compared with first-line teriflunomide treatment, early first-line ofatumumab initiation was projected to result in 35.6% fewer patients progressing to EDSS ≥7 and 27.8% fewer relapses. The ofatumumab cohort required 7.3% reduced informal care time… A 3-year delay in ofatumumab treatment (3-year teriflunomide + 7-year ofatumumab) was projected to result in 32.2% more patients progressing to EDSS ≥7, 20.2% more relapses, 5.4% increased informal care time, ……compared with early ofatumumab initiation.

Conclusions. This study highlights the benefits of early initiation of high-efficacy therapy such as ofatumumab vs its delayed initiation for improving the outcomes in RMS patients (having characteristics similar to those of patients included in the ASCLEPIOS trials). Ofatumumab treatment was projected to provide improved long-term clinical, societal, and economic outcomes vs teriflunomide treatment in RMS patients from a Spanish societal perspective.

CoI Multiple

Disclaimer. These are the views of the author….is it just me? Am I the odd one?

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  • Well written and agree except from that natalizumab is not quite safe, for example in neuromyelitis optica (an alternative diagnosis to MS) might make things worse. Give cortisone and speed up the diagnostic work-up.

    • Is it that natalizumab makes things worse or that it does not work. If it is the later ineffective treat is same as no treat so the individual has the same risk.. in some studies the relapse occurs 45- over 200 days long enough to do a AQP4 test

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