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agate
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 Posted: Sun Jul 28, 2013 1:35 pm Post subject: Drs. Vollmer & Corboy on DMTs & SPMS |
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From a Continuing Medical Education activity called "Achieving Optimal Outcomes for Patients with Multiple Sclerosis" and sponsored by the PeerView Institute and the University of Florida College of Medicine (May 29-June 1, 2013).
Drs. Timothy L. Vollmer and John N. Corboy are both professors of neurology at the University of Colorado School of Medicine and co-directors of the Rocky Mountain MS Center at the Anschutz Medical Campus in Aurora, CO.
From the "Faculty Q & A" section of the presentation:
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What is the evidence that continued disease-modifying therapy for secondary progressive disease does or does not... reduce ultimate disability, or is there any evidence of the ultimate disability of secondary progressive MS when continuously treated with any of the DMTs, and is there any evidence based on MRI data or clinical data on this?
Dr. Vollmer:
So the issue here is, I think we're thinking about it in the wrong way. If you look at the studies, take the interferon beta trials. There's the European trial and there's the North American trial [Kappos L et al. Neurology. 2004;63:1779-1787]. The fundamental difference between those trials was the age of the patients. The patients in the European trial tended to be younger and had very active disease, were in the progressive phase of disease. We saw a clear effect of interferon beta-1b in that population.
In the North American population, we did not see it in the overall effect, but they were about 6 years older, and in fact, we had already culled all the active patients out, because at that time we were already convinced that treating inflammation was important.
So the issue is not whether you're called secondary progressive or relapsing-remitting. The issue is, are you still in the inflammatory phase of the disease as measured by relapse rate, as measured by new MRI lesion activity, as measured by rapid progression of disability, and as measured by age? Basically, if you're less than age 55, you're very likely to still be in the active phase of the disease, and therefore you can benefit from the therapies.
The second issue is that your expectation in secondary progressive disease needs to be realistic. You're not going to make these patients better. The best you can do is slow down the rate at which they get worse.
Neuroplasticity, unfortunately, also decreases as a function of age. So you've got brain volume, and the double-whammy with your plasticity going down, and that, combined with loss of cognitive reserve and neural reserve, explains why in our older patients that have already got fixed disability and are progressive we cannot expect that the therapeutic goal should be to make them better.
Dr. Corboy:
And I guess I would just add one other thing that what is greatly missing is the opposite question. If you take patients off medications at, say, age 60—just to pick a number out—who have secondary progressive MS or, for that matter, primary progressive MS, is there any data that that is dangerous?
And the answer to that is no, we don't have any data that taking people off these medications is dangerous at that point in time, and that would be one way to determine actually what the ongoing effect would be for those patients.
So I think the real answer is, it's difficult to show over a prolonged period of time that there is a delay in patients going into secondary progressive disease. There are fewer patients who go into secondary progressive disease who are actually measuring the effect. But I would otherwise agree with everything that Tim said. |
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agate
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| Posted: Wed Aug 14, 2013 6:54 pm Post subject: |
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Another couple of excerpts from this:
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Dr. Vollmer: We've got just two other questions here. One was, what data do you use to stop all the drug therapies?
In terms of disease-modifying therapies, this is a challenge, as John mentioned. If I have
patients that are in their 60s, they've been stable for 5 years, their MRI has been stable
for 5 years, and they're having any kind of negative effects, toxic side effects, and they
want to go off, then I will take them off and we'll monitor them pretty close, and see them every 3 months and do MRIs. I don't know whether that's the right thing to do. We just need to develop those paradigms. |
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Dr. Vollmer: And the second question was, have you seen relapses in patients over the age of 60?
Yes, I've seen them in 70-year-old patients. So, again, each patient's individual. That's
why we have to develop better strategies to really be specific about our goals.
Dr. Corboy:
And to add to that, the age issue is partially age and partly onset of disease. So I saw a patient around Christmas, onset of disease age 65, typical relapsing MS. At age 70, she had an acute attack with three enhancing lesions. So for her, everything was sort of frame-shifted down based less on age and more on disease duration. So I think there's still a wide variation.
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