Is DMT Use Safe For Elderly Patients with Multiple Sclerosis?

Tanuja Chitnis, MD, a professor of Neurology at Brigham and Womens Hospital

Tanuja Chitnis, MD

The findings of a longitudinal cohort study of elderly multiple sclerosis (MS) patients have suggested that the use of disease-modifying therapy (DMT) is safe in older patients and that these patients perhaps show less burden from disability and a lower annual relapse rate (ARR) than previous literature has implied.¹

The investigators, including Tanuja Chitnis, MD, a professor of neurology at Brigham and Women's Hospital, found that the adverse events (AEs) related to treatment with a DMT were the most prevalent among those who were treated with first-generation therapies—45.4% of those treated with interferon beta (15 of 33 patients) and 45.7% of those treated with glatiramer acetate (27 of 59 patients) reported experiencing a drug-related AE.

Conversely, for novel oral and infusion therapies, the incidence of treatment-related AEs was much lower, at 39% (25 of 64 patients) and 6.7% (3 of 45 patients), respectively. The findings were presented in a late-breaking poster session at the Americas Committee for Treatment and Research in Multiple Sclerosis (ACTRIMS) 2019 Forum in Dallas, Texas.

Chitnis and colleagues noted that all in all, the majority of AEs were deemed mild, with few considered severe and none leading to fatalities. The most common were injection site reactions. These findings, though observational in nature, they wrote, warrant a prospective trial “in order to assess the incidence of [drug-related AEs] in old age.”

“Although disease onset typically occurs in the young, the prevalence of MS in older age has increased,” they wrote. “This patient population is understudied and presents with unique challenges, including the prevalence of progressive forms [of disease] and the safety profile of disease-modifying therapies.”

The study included 195 patients with MS from the CLIMB study who were 65 years or older and had more than 5 clinic visits after reaching that age.² The study included a retrospective review of all relevant demographic and clinical data, including comorbidities, disability scores (as determined by the Expanded Disability Status Scale [EDSS]), DMT compliance and administration, AEs, and magnetic resonance imaging (MRI) outcomes such as radiological attacks.

The cohort presented with low AARs at baseline (0.05 ±0.15) and a moderate rate of disease progression, with 18.9% of patients with relapsing MS progressing to secondary progressive MS. Notably, a high number of patients were untreated (41%), though the investigators noted that this proportion decreased by the time of the patients’ last visits (36.4%).

Historically, literature has suggested that older adults with MS are more likely to have a decreased health-related quality of life. One review in the Journal of Neuroscience Nursing from Marijean Buhse, PhD, RN, NP, noted³ that in one study, more than 50% of patients over the age of 65 with MS (n = 53) reported impaired mobility while almost half acknowledged pain and spasticity,⁴ and in another that 85% of older persons with MS (n = 179) required assistance with activities of daily living, and 40% received home care services.⁵ In the second study, one-third of the group over the age of 65 years reported fair-to-poor health.

The same review acknowledged that an estimated 90% of people with MS who are currently in their 20s may live into their 70s with the disease and that approximately one-quarter of people with MS are mature adults over 65 years old.³

Although, in addition to the poster presented at ACTRIMS, a 2015 systematic review in Neuroepidemiology by Tomas Kalincik, PhD, implied that “relapse incidence is known to decrease with time, represented either by patient age or by MS duration,” and “that older age is relatively more closely associated with decline in relapse activity than MS duration.” The review showed that younger age with clinically defined MS was associated with a hazard ratio (HR) of 1.22 (CI, 1.16 to 1.20) per 10 years for relapse risk.⁶

REFERENCES

1. Rosso M, Gonzalez CT, Manieri M, Healy BC, Weiner HL, Chitnis T. Longitudinal study of disease burden and complications in a cohort of multiple sclerosis patients over the age of 65. Presented at: ACTRIMS 2019 Forum; February 28 to March 2, 2019; Dallas, TX. Poster #LB316.

2. Comprehensive Longitudinal Investigation of Multiple Sclerosis at Brigham and Women’s Hospital. Partners MS Center website. Published 2017. mscenter.partners.org/adult-ms/climb-study. Accessed February 28, 2019.

3. Buhse M. The elderly person with multiple sclerosis: clinical implications for the increasing life-span. J Neurosci Nurs. 2015;47(6):333-339. doi: 10.1097/JNN.0000000000000172.

4. Klewer J, Pohlau D, Nippert I, Haas J, Kugler J. Problems reported by elderly patients with multiple sclerosis. J Neurosci Nurs. 2001 Jun;33(3):167-71.

5. Minden SL, Frankel D, Hadden LS, Srinath KP, Perloff JN. Disability in elderly people with multiple sclerosis: An analysis of baseline data from the Sonya Slifka Longitudinal Multiple Sclerosis Study. Neurorehabilitation. 2004; 19(1):55-67. Abstract #55Y67.

6. Kalincik T. Multiple sclerosis relapses: epidemiology, outcomes and management: a systematic review. Neuroepidemiology. 2015;44:199-214. doi: 10.1159/000382130.