Neural Regeneration Research ›› 2018, Vol. 13 ›› Issue (11): 1871-1874.doi: 10.4103/1673-5374.239432

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Sequencing of high-efficacy disease-modifying therapies in multiple sclerosis: perspectives and approaches

Francois Grand’Maison1, Michael Yeung2, Sarah A. Morrow3, Liesly Lee4, Francois Emond5, Brian J. Ward6, Pierre Laneuville7, Robyn Schecter8   

  1. 1 Neuro Rive-Sud, Hôpital Charles LeMoyne, Greenfield Park, Quebec, Canada
    2 Clinical Neurosciences, Foothills Medical Centre, Calgary, Alberta, Canada
    3 London Health Sciences Center (LHSC), Western University, London, Ontario, Canada
    4 Department of Neurology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
    5 Centre Hospitalier Universitaire de Québec - hôpital de l’Enfant-Jésus, Quebec City, Quebec, Canada
    6 Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
    7 Department of Medicine, McGill University, Montreal, Quebec, Canada
    8 Novartis Pharmaceuticals Canada Inc., Dorval, Quebec, Canada
  • Received:2018-07-23 Online:2018-11-15 Published:2018-11-15
  • Contact: Francois Grand’Maison, MD,fgrandm@videotron.ca
  • Supported by:

    This manuscript was funded by Novartis Pharmaceuticals Canada Inc.

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Abstract:

Multiple sclerosis (MS) is characterized by chronic inflammation in conjunction with neurodegeneration within the central nervous system. Most individuals with MS begin with a relapsing remitting course that later transitions to secondary progressive MS. Currently available disease-modifying therapies (DMTs) for relapsing MS have been demonstrated to reduce disease activity, however most patients require a change in therapy over the course of their disease. Treatment goals include the prevention of relapses and disability accumulation and to achieve this objective requires careful planning. Sequencing of DMTs for individual patients should be designed in such a way to maximize disease control and minimize risk based on the mechanism of action, pharmacokinetic and pharmacodynamic properties of each therapy. This includes the DMT patients are being switched from to those they are being switched to. The reversibility of immune system effects should be a key consideration for DMT sequence selection. This feature varies across DMTs and should factor more prominently in decision making as newer treatments become available for the prevention of disability accumulation in patients with progressive MS. In this short review, we discuss the landscape of existing therapies with an eye to the future when planning for optimal DMT sequencing. While no cure exists for MS, efforts are being directed toward research in neuroregeneration with the hope for positive outcomes.

Key words: relapsing multiple sclerosis, high efficacy disease-modifying therapies, treatment optimization, treatment sequencing, therapeutic inertia, sub-optimal treatment, progressive disease, immune effects