At MS Paris 2017, MD Magazine sat with experts and key opinion leaders in the treatment of multiple sclerosis (MS) to discuss the important and innovative topics from the conference.
John Corboy, MD, a professor of neurology and the director of the Rocky Mountain MS Center at the University of Colorado, discussed the lack of information in multiple sclerosis research about why or when patients with multiple sclerosis would like to stop using disease-modifying therapies.
Corboy is part of the DISCO-MS trial, which is currently enrolling patients aged 55 years and older, in order to explore these data over the next 2 to 3 years, expecting results in 2020. The trial will explore how the risk of relapses and new MRI lesions is affected by the halting of DMTs.
John Corboy, MD:
The question is, "is there an ongoing benefit of using the medication, and does that benefit outweigh potential risks?" If the benefit is potentially going down as you age, and if the risk is potentially going up as you age, those lines may cross where you do not really see that the benefits outweigh the risks, in which case - especially with extremely expensive medications such as in our world [of MS] - it would at least be the impetus to us to say, "we should try to do a study to figure this out," and that's what we're doing now with DISCOMS.
A. That is true that when they go off, they are no different from people that stay on, or...
B. That maybe they do significantly worse for whatever reason when they go off, or...
C. They might do a little bit worse - maybe there is a slightly increased risk of having a small scan change - and then the patient will have to say, "Well, is that enough for me to continue to use the medication over a prolonged period of time?"
In 3 years, we'll have data that will say 1 thing or another, or perhaps something in between. We may be able to see, in a relatively restricted group of people - because this is people 55 years and older who have been inactive. No scan change or no relapse for at least 5 years while continuously taking 1 of the approved disease-modifying therapies. At least in that group of people who we think are at relatively low risk for recurrence of disease activity, we'll either be able to say:
So we may get sort of an in-between answer, and that is where patient-reported outcomes and that is where other data and asking a simple question: do you feel better, worse, or about the same now as when you started the study with regard to your relationship with the drug? That is, are you happier being on the drug if you are still on it, or off if you are off it, and what is the nature of that relationship now over a 2-year period of time?
It could be that people have a little bit of new disease activity, but they feel so much better being off of the medication. You can look at that as less cost, [fewer] side effects, whatever else it might be, that they are willing to make that trade-off. It is not for us to decide what they should view as a trade-off. None of the drugs we use are perfect. None of them stop all disease activity, so we know there is going to be some level of disease activity with many of these drugs, even as people age. It might well be that we do not hit a perfect no-disease-activity outcome, and yet people still find that is acceptable to them and they would like to stay off medication.