Balancing the Risks and Rewards of Multiple Sclerosis Medications

There are many factors to consider in treating multiple sclerosis (MS), since patients can suffer relapses, Stephen Krieger, MD, explains.

As the disease progresses, Krieger notes “the inflammatory component … does seem to fade in many patients over the years,” so relapses become more sporadic.

As a result, clinicians who treat MS “have lots of rules about when to start medicines, (but) we don’t really have rules about when to stop them,” he says, adding “that is when to think, ‘This is a patient who hasn’t had a relapse in a decade, hasn’t had a new lesion in a decade. Should I stop the medicine and see how they do?’ ”

Fellowpanelist Clyde Markowitz, MD, calls the prospect of stopping a medication that way “a scary, scary, scary thought,” to which Krieger agrees, but also points out, “we’re balancing, as you said, risks of medicines.”

Krieger says physicians should also consider the possibility of relapsing-remitting multiple sclerosis (RRMS) transitioning to secondary progressive multiple sclerosis (SPMS).

“These distinct categories are, in reality, not distinct categories; rather, one leads into the next, and it’s hard to know where RRMS ends and SPMS begins,” Krieger explains.

In one study where MS patients were asked how likely they would be to desire a change in their prescriptions based on a number of factors, “in the longer disease duration, there were always a higher proportion of MS patients who were willing to switch to a new treatment,” Patricia Coyle, MD, says.

Responding to questions posed by her fellow panelists regarding the study, Coyle adds, “I believe that the patient living with their MS experiencing disease activity … is much more likely to be willing to take some risk to control disease than the very newly diagnosed patient who hasn’t experienced it. That would be the logical explanation.”

Andrew Goodman, MD, FAAN, notes the question of where to go with a patient’s medication can be as complex to solve as the diagnosis.

“I think what we’re hearing is what we have always tried to do, which is try to weigh the risk of therapy versus the risk of disease,” Goodman says. “And the risk of the disease becomes more and more apparent to a patient over time when they’ve experienced more and more of the impact of the disease. Therefore, their calculation (of) the risk of the disease changes over time.”