Factors to Consider for First-Line Therapy for MS

Fred D. Lublin, MD: With this issue of how you choose your first therapy, we get asked fairly frequently by pharmacy benefit providers, “Give us an algorithm,” because that lets them know who to go negotiate with first. You know, start with A, then B. There are some disease states where you can do that. I don’t think you can do that in MS [multiple sclerosis]. I think you well know the conversation on choosing a therapy is about an hour long.

And the American Academy of Neurology in their guidelines, one of the wisest things they put in there was that you should do the diagnosis at one visit, and the discussion of the therapy in the next visit because they’re both very complicated, and after you do the one, the patient may not be in a position to really choose.

But there are so many different factors. There’s your assessment of how active their disease is and what their prognosis is, as difficult as that is because of our lack of ability; their risk-taking capacity; what they’ve learned from the outside; where they are; pregnancy. We do the second most family planning in our institution after the OB/GYNs [obstetricians and gynecologists]. You ought to get pictures; we make them bring the babies in. But it’s a big part of what we do because very often someone will come in, a young woman, that’s our model patient, and there will be a decision, “Well we’re going to put you on this medication—are you going to try and start your family?”

Then there are insurance issues and what route of administration they want to take. And so there’s quite a bit involved, and it’s a long conversation. At least my view is we don’t have this kind of algorithm. Thoughts?

Patricia K. Coyle, MD: I would agree.

Peter A. Calabresi, MD: I would agree; everyone is different.

Fred D. Lublin, MD: Yes. One of the questions that we’re asked to discuss is, what therapies to use as first-line treatment. And I think I’ll turn that around and say, what therapies wouldn’t you use as first-line treatment? Amit?

Amit Bar-Or, MD, FRCP: Other than alemtuzumab, for bone marrow transplantation, as an unapproved therapy, I think all the therapies in the armamentarium could be considered for first-line therapy.

Stephen C. Krieger, MD: I would agree with that. Recognizing that higher efficacy medicines probably work best in early highly inflammatory disease, I still think very few patients up front merit the risks of those strategies. And so I would use, or at the very least discuss, all of the others.

Peter A. Calabresi, MD: I agree.

Fred D. Lublin, MD: We’re all in agreement. And I think that what we’re seeing out there, as we get more and more agents along, certainly more of what we think are higher efficacy agents, we’re seeing their uptake faster and sooner. And we are sometimes even not following the label per se, there are all these different labels; our decisions aren’t necessarily based on the data but rather on some opinions.