Dr. Ontaneda: The selection of disease-modifying agents in multiple sclerosis [MS] is a significant challenge for a neurologist. And probably the best answer is that the selection of treatment should be individualized. The neurologist should take a careful look at several different factors to make a treatment decision. These include: 1) Disease activity: MRI disease activity, relapse disease activity, and progression of disability or accrual of disability activity. 2) Prior treatment response: What medications has the patient previously been on? Did they respond to those treatments? Did they fail those treatments? Did they have side effects to those treatments? 3) What are the patient baseline characteristics? We look at these increasingly to identify which patients are at higher risks of developing certain complications on specific agents. And, 4) what is the patient risk-benefit profile? This is a very important question that sometimes takes some time to answer. The neurologist should form some rapport with the patient and understand how aggressive the patient wants to be with their treatment.
Disease activity is probably what is easiest to identify for most neurologists. This includes understanding of the relapse rate, MRI lesion activity, disability progression, and atrophy measures. So treatment should be selected to manage the inflammatory activity a given patient has. Now, although this is sometimes difficult to do, certainly a patient with one enhancing lesion is not going to be the same as a patient with
Prior treatment response will give the clinician a good idea about how aggressive the disease might be and how they might respond to subsequent therapies. For example, a patient who has failed natalizumab is probably not the same as a patient who has failed one of the injectable therapies.
Oral agents should be selected which have the best likelihood of controlling disease activity. An understanding of the effectiveness of each medication compared to placebo will be helpful to make the selection. Now, by no means am I saying that we should compare the effect of medications against placebo, against each other—we know that methodologically that has its concerns [without
Patient baseline characteristics are very important in selecting
Clinicians also need to understand the risk aversion of their patients. Some individuals are willing to take considerable risks, while others are not. Evidence suggests that patients with increasing disability are more likely to take higher risks when deciding on a
Taking all these factors into consideration will help the clinician and patient decide on an appropriate treatment. As the armamentarium of MS therapies increases, the neurologist will have to be able to guide patient decision, while at the same time understanding patient wishes.
Frequently, I am asked about the role of oral therapies as