MS Speaks
Multiple Sclerosis => MS - RESEARCH AND NEWS => Topic started by: agate on October 29, 2017, 03:38:47 pm
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Presented at the ECTRIMS congress in Paris, October 27, 2017:
Disease modifying therapy in the aging multiple sclerosis patient
J.R. Corboy
Neurology, University of Colorado School of Medicine, Aurora, CO, United States
Multiple sclerosis (MS) is an inflammatory and neurodegenerative disorder of the central nervous system (CNS), with mean clinical onset about age 30. MS changes with aging, with [fewer] new relapses and MRI changes in older patients, and many patients-- beginning in their early 40's--having slow progression of symptoms independent of new relapses or MRI scan lesions.
Those autopsied at a young age have substantial acute inflammatory CNS changes, while those autopsied after age 50 have significantly less overt inflammation. Thus, the inflammatory component of MS seems to be maximal in the young, while the degenerative component, especially as manifested by worsening brain and spinal cord atrophy, begins early and is persistent throughout aging with MS.
There are now over a dozen disease modifying therapies (DMTs) approved for MS since 1993, and these have significant impacts on development of new relapses and MRI changes, but much less effect on slow progression. Almost all clinical trials identifying benefit of MS DMTs have had a maximum age of 55, and subgroup analyses by age of many different MS clinical trials reveal that response to presently available DMTs is greatest in younger patients, especially those under age 40.
These observations suggest it may be reasonable to consider a trial off of DMTs, especially for older patients who have been clinically quiescent, but in practice many patients simply start using a DMT at clinical onset and continue indefinitely. Data addressing the possibility of a trial off of DMTs are sparse and have significant methodological limitations, but suggest it may be reasonable to consider a trial off DMTs, especially for older patients who have been clinically quiescent for a prolonged time.
We are presently enrolling patients at 15 US sites for a randomized, controlled, blinded two-year trial (DISCOMS NCT03073603) of discontinuation of DMTs in MS patients 55 and older who have had no new relapses or brain MRI scan changes for at least five years while continuously taking a DMT, and hope to have data in 2020 that will further guide clinicians in this area. The relative futility of presently available DMTs in aging MS patients, especially those with progressing symptoms, argues strongly for development of approaches that diminish neurodegeneration and enhance CNS recovery and/or regeneration.
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Disclosure: Dr. Corboy receives research funding from Med Day, Novartis, the Patient Centered Outcomes Research Institute and the National MS Society