How long should immunotherapy for MS be continued? When can therapy be stopped? These are questions that not only concern MS patients but also many neurologists. Of course, one can take the position that long-lasting stability under a therapy is absolutely desired and therefore the question of stopping a therapy for MS does not arise at all, on the other hand, one does not want to treat patients with immunotherapeutics longer than necessary. Against this background, a scientific session at this year’s ECTRIMS exclusively dealt with the question:
When it is rational to stop MS immunotherapy.
For this purpose, the currently available studies on therapy stop in relapsing MS were analyzed. The analysis showed that it is not sensible to end an MS therapy before the age of 45, even if there has been no activity for many years. The risk of relapse in older patients is rather low after stopping immunotherapy – it was shown that an age > 55 years and more than five-year clinical and MRI stability (NEDA 3) are good predictors that stopping an MS therapy succeeds. In addition, it was shown that the combination of various parameters such as age, activity, and disability can serve to define risk groups.
Patients who have only had one relapse in their life, have not had any disease activity for more than 5 years, and are older than 45 years, have a relatively low risk of relapses occurring after stopping immunotherapy, with the data mainly referring to treatment with interferons and Copaxone.
Criteria: Age and stable course
Accordingly, caution is also advised when it comes to ending high-efficiency therapy such as Natalizumab or Fingolimod – the same standards as for basic therapy cannot be applied here. Often an inflammatory rebound is observed after discontinuation of these substances.
In summary, it can be stated that in older patients > 55 years, who were > 4 years clinically and MRI stable under treatment with a basic immunomodulatory therapy, the discontinuation of the therapy can probably succeed without problems. However, definitive clarification of this important question will only be provided by the results of some prospective studies that were recently launched in various countries.
Longer dosage intervals?
A similarly interesting topic that was discussed at this year’s ECTRIMS is whether an anti-CD20 therapy (Rituximab, Ocrelizumab, Ofatumumab) should and can be continued indefinitely. For many patients with multiple sclerosis, these therapies are now a preferred treatment method. Most recently, longer dosage intervals have been discussed again and again against the background of long-term side effects. However, the experts are still unsure whether the potential benefits of extended dosing (such as improved safety) outweigh the potential risks (such as a loss of effectiveness).
There are also voices that do not deny that anti-CD20 antibodies represent a very effective therapeutic concept, but warn that the treatment-related risks, such as infections, occur cumulatively and unlimited use could be dangerous. A solution could be personalized dosing based on the recurrence of B cells. It was also discussed whether long-term maintenance therapy with anti-CD20 antibodies might represent the wrong approach and whether induction therapy with subsequent de-escalation is more sensible.
Here too, it is clear that further studies are needed to clarify how this effective concept can also be used safely in the long term.
More information about the currently approved immunotherapies for multiple sclerosis is available on the AMSEL MS treatment platform.
[Note]: The blog posts ECTRIMS (2) and ECTRIMS (3) will be published in the next two weeks.
