De-escalating and discontinuing disease-modifying therapies in multiple sclerosis - Scorecard - MDSpire

De-escalating and discontinuing disease-modifying therapies in multiple sclerosis

  • By

  • Géraldine Androdias

  • Jan D Lünemann

  • Elisabeth Maillart

  • Maria Pia Amato

  • Bertrand Audoin

  • Arlette L Bruijstens

  • Gabriel Bsteh

  • Helmut Butzkueven

  • Olga Ciccarelli

  • Alvaro Cobo-Calvo

  • Tobias Derfuss

  • Franziska Di Pauli

  • Gilles Edan

  • Christian Enzinger

  • Ruth Geraldes

  • Cristina Granziera

  • Yael Hacohen

  • Hans-Peter Hartung

  • Sinéad Hynes

  • Matilde Inglese

  • Ludwig Kappos

  • Hanna Kuusisto

  • Annette Langer-Gould

  • Melinda Magyari

  • Romain Marignier

  • Xavier Montalban

  • Marcin P Mycko

  • Bardia Nourbakhsh

  • Jiwon Oh

  • Celia Oreja-Guevara

  • Fredrik Piehl

  • Luca Prosperini

  • Jaume Sastre-Garriga

  • Finn Sellebjerg

  • Krzysztof Selmaj

  • Aksel Siva

  • Emma Tallantyre

  • Vincent van Pesch

  • Sandra Vukusic

  • Bianca Weinstock-Guttman

  • Frauke Zipp

  • Mar Tintoré

  • Ellen Iacobaeus

  • Bruno Stankoff

  • December 21, 2024

  • 0 min

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Clinical Scorecard: Reducing and Stopping Disease-Modifying Treatments in Multiple Sclerosis

At a Glance

CategoryDetail
ConditionMultiple Sclerosis (MS)
Key MechanismsPeripheral immune-mediated inflammation, immunosenescence, inflammaging, neurodegeneration
Target PopulationPeople with MS across disease stages including relapsing-remitting and progressive forms, with considerations for ageing and pregnancy
Care SettingNeurology clinics and specialized MS treatment centers

Key Highlights

  • Early initiation of disease-modifying therapies (DMTs) improves long-term prognosis in MS.
  • De-escalation involves switching to less potent DMTs, dose reduction, or extending dosing intervals, including discontinuation.
  • Age-related immune changes (immunosenescence and inflammaging) influence the benefit-risk balance of continued DMT use.

Guideline-Based Recommendations

Diagnosis

  • Classify MS as a continuum with varying inflammatory and neurodegenerative contributions rather than discrete relapsing or progressive types.

Management

  • Initiate effective DMTs early after disease onset to reduce relapses and delay progression.
  • Regularly reassess treatment plans to consider de-escalation or discontinuation based on changing benefit-risk ratios.
  • Consider de-escalation strategies including switching to less potent therapies, dose reduction, or treatment interval extension.
  • Include discontinuation as part of de-escalation strategies, especially in contexts such as pregnancy or ageing.

Monitoring & Follow-up

  • Monitor for changes in disease activity and treatment-related risks during and after de-escalation.
  • Assess immune system changes related to ageing that may affect treatment effectiveness and safety.

Risks

  • Increased risk of infections, cancer, and reduced vaccine response due to immunosenescence.
  • Potential for disease reactivation or progression if de-escalation is not carefully managed.

Patient & Prescribing Data

People with MS receiving continuous maintenance DMTs or immune reconstitution therapies (IRTs).

IRTs may induce prolonged remission allowing for treatment discontinuation or less intensive maintenance therapy; benefit-risk balance shifts with ageing and disease course.

Clinical Best Practices

  • Adopt a personalized approach to DMT de-escalation based on individual disease activity, age-related immune changes, and patient preferences.
  • Use international expert consensus and evidence-based guidelines to guide timing and modality of de-escalation.
  • Incorporate regular clinical and radiological monitoring to detect disease activity during de-escalation phases.
  • Consider special populations such as pregnant patients and pediatric-onset MS in de-escalation planning.

References

Original Source(s)

De-escalating and discontinuing disease-modifying therapies in multiple sclerosis

  • by Géraldine Androdias, Jan D Lünemann, Elisabeth Maillart, Maria Pia Amato, Bertrand Audoin, Arlette L Bruijstens, Gabriel Bsteh, Helmut Butzkueven, Olga Ciccarelli, Alvaro Cobo-Calvo, Tobias Derfuss, Franziska Di Pauli, Gilles Edan, Christian Enzinger, Ruth Geraldes, Cristina Granziera, Yael Hacohen, Hans-Peter Hartung, Sinéad Hynes, Matilde Inglese, Ludwig Kappos, Hanna Kuusisto, Annette Langer-Gould, Melinda Magyari, Romain Marignier, Xavier Montalban, Marcin P Mycko, Bardia Nourbakhsh, Jiwon Oh, Celia Oreja-Guevara, Fredrik Piehl, Luca Prosperini, Jaume Sastre-Garriga, Finn Sellebjerg, Krzysztof Selmaj, Aksel Siva, Emma Tallantyre, Vincent van Pesch, Sandra Vukusic, Bianca Weinstock-Guttman, Frauke Zipp, Mar Tintoré, Ellen Iacobaeus, Bruno Stankoff

  • December 21, 2024

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