What is the Most Effective Treatment Strategy for Patients with Secondary Progressive Multiple Sclerosis?

June 1, 2014
Carole Bullock, MA

Experts examine conflicting evidence regarding the continuation of disease-modifying therapy in patients with secondary progressive multiple sclerosis.

DALLAS -- May 31, 2014 — Despite recent advances in treatment for multiple sclerosis, the options for patients with secondary progressive disease remain limited.

The 2014 Annual Meeting of the Consortium of Multiple Sclerosis Centers (CMSC) and the Sixth Cooperative Meeting with Americas Committee for Treatment and Research in Multiple Sclerosis (ACTRIMS) concluded Saturday with “Controversies in the Treatment of Multiple Sclerosis,” a debate-style session that focused on discussion of several hot-button issues in current practice.

The first segment in the session, “Disease Modifying Therapies Should Be Stopped in Patients Who Have Developed Secondary Progressive MS,” was developed with support from the VA MC Centers for Excellence, and featured expert speakers discussing the treatment of secondary progressive disease in multiple sclerosis.

Dennis Bourdette, MD, Chair of the Department of Neurology, Roy and Eulalia Swank Family Research Professor, Executive Director of the OHSU Multiple Sclerosis Center and Co-Director of the VA MS Center of Excellence-West, introduced the first session and noted this issue was important because of ongoing uncertainties regarding the progression of secondary progressive disease, and the risks vs. benefits of additional therapies. He asked participants to consider the question of whether the current literature supports the assertion that disease-modifying therapies should be stopped in patients with secondary progressive disease.

According to Michael Carrithers, MD, PhD, associate professor of neurology at the University of Wisconsin School of Medicine and Public Health, there should be room for agents such as interferon beta-1a in the treatment of secondary progression of multiple sclerosis.

Carrithers said discontinuation of therapy may have consequences, citing a 2005 study in Acta Neurologica Scandinavica by Wu and colleagues that looked at “neurological and magnetic resonance imaging changes following discontinuation of interferon beta-1a treatment in secondary progressive multiple sclerosis. The study indicated that discontinuation of interferon beta-1a “may be associated with an increase in neurological disability and brain lesions on MRI.”

Olaf Stüve, MD, PhD, said disease-modifying therapies should be stopped in some patients who have developed secondary progressive multiple sclerosis.”

Stüve is associate professor in the Department of Neurology and Neurotherapeutics and associate professor in the Department of Immunology at University of Texas Southwestern Medical Center, and chief of the Neurology Section at VA North Texas Health Care Systems.

He cited several studies, including one by the European Study Group, showing some benefit from interferon beta-1b in this patient population. In this study, “interferon beta-1b delayed progression for nine to twelve months over two to three years,” he said.

The North American Study Group on interferon beta-1b in secondary progressive multiple sclerosis was a placebo comparison trial that found that SPMS occurred at an average of four years.

Another study that compared interferon beta-1a with placebo in secondary progressive multiple sclerosis looked at changes from baseline to month 24 in the MS Functional Composite (MSFC) score. The authors reported that median MSFC Z-score change was reduced 40% in the interferon beta-a group, driven mainly by improvements that measured arm function and cognition. Patients in the treatment arm also had one-third fewer relapses than the patients in the placebo group.

Disease-modifying agents should be reserved for “defined secondary progressive multiple sclerosis (5 years relapse free) and meaningful outcomes must be defined,” Stüve concluded.

Bourdette pointed out that regardless of which therapy is chosen, one important element for success is patient compliance. In the future, he said there may be better tools to tailor the disease-modifying agents for multiple sclerosis, and more favorable dosing strategies.

Both sides may find common ground as they focus on costs, follow-up care, and reimbursements for emerging treatments, Bourdette said.