Multiple sclerosis RRMS Choice of Initial Disease modifying Drugs

Disease Modifying Therapies (DMT) for Relapsing Remitting MS (RRMS) include oral agents (dimethyl fumarate, teriflunomide), infusion therapies (natalizumab, ocrelizumab), and injections (interferon beta, glatiramer). Selection depends on disease severity, side effects, and patient preference. Oral agents are easy to use but require safety monitoring, while infusions target active disease but have higher risk profiles. Injections are safer but less potent. Treatment usually continues indefinitely.

2024-01-06 05:49:14 - Editor

Disease Modifying Therapies for RRMS

Oral Agents

Oral agents, such as, dimethyl fumarate (the starting dose is 120 mg twice daily. After 7 days, the dose is increased to 240 mg twice daily), teriflunomide (14 mg daily), monomethyl fumarate (starting at 95 mg twice daily for 7 days and then increased to the maintenance dose of 190 mg twice daily), fingolimod (0.5 mg daily), siponimod ( starting at 0.25 mg daily on days 1 and 2, followed by once daily doses of 0.5 mg on day 3, 0.75 mg on day 4, and 1.25 mg on day 5, to reach the patient's prescribed maintenance dose from day 6), ozanimod (starting at 0.23 mg daily on days 1- 4, then, escalate to 0.46 mg daily on days 5-7, then escalate to 0.92 mg daily from day 8) and cladribine (at a cumulative dosage of 3.5 mg/kg divided into two yearly treatment courses (1.75 mg/kg per treatment course to be given every 6 months. Each treatment course is divided into two treatment cycles of four or five days separated by approximately four weeks). (1, 2, 3, 4, 5, 6)

Infusion Therapy

Infusion therapy, such as, natalizumab (300 mg intravenous (IV) infusion every 4 weeks), ocrelizumab at an initial dose of 300 mg IV infusion, followed by a second 300 mg IV infusion 2 weeks later. Six months later, it is given at 600 mg IV infusion every 6 months and alemtuzumab (12 mg daily for five consecutive days then 12 mg daily for three consecutive days 12 months later). (7, 8, 9)

Injection Therapies

Injection therapies, such as, interferon beta-1a (30 mcg intramuscular injection once a week), interferon beta-1B at 0.25 mg every other day subcutaneously, and glatiramer (Either 20 mg daily or 40 mg three times a week by subcutaneous injection). (10, 11, 12)

Choice of DMTs Based on Individual Needs:

Amongst DMT, the choice of a specific starting agent should be individualised based on current disease activity status, comorbidities, side effects and patient's preference. Oral agents are considered primarily for patients who want to avoid injections and prefer a self administered medication. However, these agents are associated with serious side effects, so clinicians must monitor their toxicities. Dimethyl fumarate is the most widely used DMT with its better safety profile compared to other agents. While, cladribine is reserved to patients who failed other oral lines. Infusion therapy class is particularly for patients with more active disease and those who mostly value efficacy and less worried about safety. These agents are associated with serious side effects including progressive multifocal leukoencephalopathy (PML). Alemtuzumab is usually reserved for patients who have an inadequate response to other agents. While, injection therapy class is for patients who value safety and are less concerned with achieving the highest effectiveness. ((13, 14, 15)

Duration of DMT Therapy

Most DMT are continued indefinitely in clinically stable patients with RRMS unless safety concerns arise. (16, 17)

References

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