Oral Therapies for Multiple Sclerosis

%jwplayer%

The MD Magazine Peer Exchange "Modifying the Course of Multiple Sclerosis in New Ways: The Latest Advances in Treatment" features a distinguished panel of physician experts discussing key topics in multiple sclerosis (MS) research and management, including the latest insights into MS pathophysiology, new medication options and their application in clinical practice, and more.

This Peer Exchange is moderated by Paul Doghramji, MD, who is a family physician at Pottstown Memorial Medical Center in Pottstown, PA, and medical director of Health Services at Ursinus College, in Collegeville, PA.

The panelists are:

• Fred D. Lublin, MD, FAAN, FANA, the Saunders Family Professor of Neurology and director of The Corinne Goldsmith Dickinson Center for Multiple Sclerosis, and co-chief editor of Multiple Sclerosis and Related Disorders at the Icahn School of Medicine at Mount Sinai
• Patricia K. Coyle, MD, professor of neurology, vice chair of Clinical Affairs, and director of MS Comprehensive Care Center
• Suhayl Dhib-Jalbut, MD, professor and chief of the Department of Neurology at Rutgers, Robert Wood Johnson Medical School

Fingolimod is an oral treatment that is given once daily for the treatment of MS. Dhib-Jalbut said that its dosing makes it convenient to take, and it’s “at least as effective” than the injectable medications, although he added that no head-to-head trials have been conducted. Fingolimod can cause bradycardia, he said, so it is not recommended for patients with certain cardiac conditions, and all patients who receive it should be monitored for 6 hours following the first administration. Other considerations when using fingolimod is that patients need a retinal examination and vaccination against Varicella if they are not already immune.

Teriflunomide is also an oral agent taken once a day. Lublin said, “It’s one of a very small number of agents that actually has shown effects on enhancing disability outcomes in two studies.” It is reasonably well tolerated, he said, and “behaved similarly to high-dose, high-frequency interferon,” in a short study.

Dimethyl fumarate operates with a different mechanism of action, said Coyle. She mentioned a study presented at the American Academy of Neurology meeting that showed that patients who had had breakthrough activity on interferon betas who were then switched to dimethyl fumarate were able to attain better disease control. She added, “You can critique that sort of study but I think in principle it says that, with 12 FDA-approved disease-modifying therapies encompassing 8 distinct mechanisms of action, if you’re having efficacy issues on one you want to make a switch and you probably want to switch to a different mechanism of action agent.”

Two major side effects occur with the use of dimethyl fumarate: gastrointestinal upset and flushing. Real-world trials showed more flushing and more decreases in white blood cell or lymphocyte count than what was found in clinical trials, said Coyle. Although there was a very small percentage of patients with a low lymphocyte count, Coyle said that it is “of slight concern” due to the “single case of a very bad brain infection, PML, in an MS patient on dimethyl fumarate.” This patient had had a very low lymphocyte count for 3 and a half of the 4 years on therapy, “so I think all of us are paying more attention to that now.”