There are currently, 15 disease-modifying agents approved by the U.S. Food and Drug Administration (FDA) to treat multiple sclerosis (MS).
The goal of disease-modifying treatment is to reduce the early clinical and sub-clinical disease activity that is thought to contribute to long-term disability.
Several important themes emerge from the growing body of evidence in MS therapeutics:
1.) Early successful control of disease activity – including the reduction of clinical and sub-clinical attacks and the delay of the progressive phase of the disease – appears to play a key role in preventing accumulation of disability, prolonging the ability of people with MS to remain active and engaged, and protecting quality of life.
2.) Physical impairments comprise only one aspect of disability that results from early disease activity and disease progression. Cognitive impairment and fatigue are common early in the disease process and cause disability independent of physical function. In addition, common physical comorbidities in MS are associated with persistent fatigue, and depression at baseline is associated with worsening fatigue over time.
3.) Prognosis at the individual level remains highly variable and unpredictable.
4.) Adherence to treatment is important to efficacy and may be impacted by a wide range of factors requiring early identification and intervention.
In 2018, the American Academy of Neurology published the Practice Guideline: Disease-Modifying Therapies for Adults with Multiple Sclerosis. The Guideline provides evidence-based recommendations for starting, switching and stopping disease-modifying agents.
These recommendations consider the patient’s perspective in the complex decision-making process in order to enhance shared decision-making. Refer to the full Guideline at AAN.com/guidelines.
The following points highlight the importance of early treatment:
- Neuroinflammation and neurodegeneration occur simultaneously throughout the disease course
- Individuals with a first clinical event accompanied by MRI findings consistent with MS have a high probability of experiencing further clinical disease activity
- Individuals with radiologically isolated syndrome (RIS – the incidental finding of MS-like lesions in the absence of known clinical relapses) are at significant risk for subsequent clinical disease activity
- Early disease activity and disease course appear to impact long-term disability
- Cognitive changes, depression and fatigue occur very early in the disease process
- So-called “benign MS” may not be benign for many people
Although none of the available treatments are fully effective in stopping MS disease activity or disease progression, evidence points to the favorable impact of treatment following a first clinical event: delaying conversion to clinically-definite MS; and reducing brain atrophy and disability worsening.
Each of the approved disease-modifying therapies has been shown to provide significant benefits in relapsing and progressive forms of MS.
Once a disease-modifying treatment is initiated, evidence suggests that treatment needs to be ongoing for benefits to persist. Cessation of treatment has been shown to negatively impact clinical and MRI outcomes.
Disease-modifying treatment has also been found to be beneficial in the treatment of pediatric MS, and in women and men in their reproductive years.
Although there is still much that we do not fully understand about the pathophysiology of MS, the last 20 years have provided a significant number of treatment options that improve prognosis and quality of life for people with MS. Furthermore, the growing body of evidence highlights the importance of early and ongoing access to and treatment with disease-modifying therapies.
The information provided in this article is an excerpt from The Use of Disease-Modifying Therapies in Multiple Sclerosis: Principles and Current Evidence, a consensus paper by the Multiple Sclerosis Coalition––a collaborative network of independent MS organizations, including United Spinal Association, focused on improving the quality of life for those affected by MS.