Early treatment: PreCISe-ly what the patient needs

Time to first treatment and risk of disability pension in relapsing-remitting multiple sclerosis

Background Initiation of disease-modifying therapy early in the disease course of relapsing-remitting multiple sclerosis (RRMS) has demonstrated beneficial effects on clinical outcomes, but socioeconomic outcomes remain largely unexplored. Objective To investigate the association between the delay from disease onset to first treatment and the hazard of disability pension. Methods We performed a population-based cohort study with data from the nationwide Danish Multiple Sclerosis Registry and Danish nationwide registries. Patients with a disease onset between 1 January 1996 to 5 April 2016 were followed until disability pension or a competing risk/censoring event. 7859 patients were assessed for eligibility of which 5208 were included in the final cohort. Key inclusion criteria were: a diagnosis of multiple sclerosis, relapsing-remitting phenotype, treatment in history, age 18-65 years and an Expanded Disability Status Scale≤4. Patients were categorised according to time from onset to first treatment: within 1 year (early), between 1 and 4 years (intermediate) and from 4 to 8 years (late). Results Of the 5208 patients, 1922 were early, 2126 were intermediate and 1160 were late. Baseline clinical and socioeconomic variables were well balanced. The hazard of receiving disability pension increased with increasing delay of treatment initiation compared with the early group. Cox regression estimates adjusted for clinical and socioeconomic confounders: intermediate (HR, 1.37; 95% CI, 1.12 to 1.68) and late (HR, 1.97; 95% CI, 1.55 to 2.51). Conclusion Early treatment initiation is associated with a reduced risk of disability pension in patients with RRMS. This finding underlines the importance of early diagnosis and treatment on a patient-centred, socioeconomic disability milestone.

Current therapeutic recommendations in multiple sclerosis

Recent clinical studies in multiple sclerosis have provided new data on glatiramer acetate, interferon-beta preparations and natalizumab, which will have important implications for optimising patient care. Once a diagnosis has been made with confidence, early initiation of immunotherapy is warranted because of the presence of continuous inflammatory disease activity. Approval for therapy in patients with a clinically isolated syndrome has been granted to several first-line treatments, and most recently to glatiramer acetate. The utility of systematic frequent MRI monitoring of disease activity and response to therapy is not yet clearly established. Treatment efficacy after initiating therapy at the first demyelinating episode has to be followed carefully and re-evaluated whenever necessary. The occurrence of further relapses, confirmed disability progression or MRI evidence of persistent or aggravated disease activity would be regarded as evidence for an inadequate treatment response. However, limitations of clinical scores in faithfully reflecting disease activity at all times, as well as uncertainties about the discriminatory capacity of surrogate measures such as MRI, need to be clarified before clear-cut recommendations on treatment failure can be advocated. Escalation therapy is reserved for patients presenting with 'aggressive disease', which can be operationally defined as the occurrence of two severe relapses within twelve months, together with either MRI evidence for persistent disease activity or a two-point progression of disability on the EDSS.