Dr. Thomas: The answer is, of course, yes. All three of the FDA-approved oral therapies—fingolimod, teriflunomide, and dimethyl fumarate [BG-12]—are approved as first-line therapies (Kappos L, et al. N Engl J Med. 2010;362:387‐401; Khatri B et al. Lancet Neurol. 2011;10:520. Cohen JA et al. N Engl J Med. 2010;362:402‐415).
Both doctors and patients are excited about oral therapies, because what patient wouldn’t want to take a pill rather than injection if they could? But they're also a little bit cautious because the clinical trials or precursor molecules to these oral therapies have had some side effect issues, or in some cases safety issues. A recent survey indicates 10% or 11% of respondents [neurologists] consider using oral therapies, and the doctors who are cautious—and I would put us in that category—we really spend a lot of time, when we talk to other doctors, trying to find out their experience with the oral therapies, to figure out if there are any safety or monitoring issues that we were not aware of.
Interestingly, patients will often come to us and [say] they're very interested in the oral therapies when they're announced and approved. You try to present the information from the package insert in a very clear, careful, unbiased way, and often you'll hear patients say, "That sounds really interesting. Maybe I'll wait six months and see how it does. Maybe I'll wait a year and see how it does." It gives them sort of a light at the end of the tunnel that one of the orals may be both effective and safe, but they would like somebody else to be the first one to try the medication.
This may be because of our experience with natalizumab. Natalizumab is a strong medication to suppress MS exacerbations, but also had some serious infection issues that we weren't aware of at the time it was approved. The drug was pulled from the market and then reintroduced with a safety monitoring program. That really heightened the patients’ awareness that whenever a new drug comes out there could be safety issues.