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Multiple Sclerosis Centers of Excellence

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Making the Decision to Use DMTs for Multiple Sclerosis

James Bowen, MD, Medical Director, Multiple Sclerosis Center

Swedish Neuroscience Institute, Seattle, WA

 

Overview

What are some reasons patients choose to use DMTs?

What are some reasons patients hesitate or wait to use DMT medications? 

Serial MRI Scans

 

Overview

Most patients with MS should be offered a disease-modifying therapy, and most patients will choose to use them.  Fortunately, we now have several medications to slow the course of MS. These medications have all been proven to benefit MS patients in well-designed large studies. Based on the results of these studies, the National Multiple Sclerosis Society states: “Initiation of therapy is advised as soon as possible following a definite diagnosis of MS and determination of a relapsing course.” Patients must decide for themselves, with the help of their doctor, whether they wish to use one of these medications.

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What are some reasons patients choose to use DMTs?

  • These are the only medications proven to slow the disease. After 20 years, 15-20% of untreated patients are in wheelchairs and another 50% need aids to walk. Use of these medications should improve these odds and lessen the disability that develops over time.
  • Some patients believe they do not have enough attacks to warrant use of DMT’s. However, patients are not aware of most MS attacks. A very conservative estimate is that patients have ten silent attacks for every attack they are aware of. These “silent” attacks can eventually affect memory, cognition, and other important areas.
  • We now know that one of the effects of MS can be in thinking or memory loss. This can be a serious symptom and decreasing this loss should be a high priority.
  • Some patients wait to see if they will become more disabled before using DMT’s. However, these drugs do not reverse damage; they decrease future damage. Our advice is to start DMT’s before more damage occurs.
  • There is some evidence that patients using DMT’s early in the disease leads to a better response than those treated later in the disease. There are even studies indicating benefit in patients using these drugs after their first attack, before the diagnosis of MS can technically be made (the diagnosis of MS requires at least two attacks). This first attack is called Clinically Isolated Syndrome (CIS), and several of the medications are FDA approved for use in CIS.
  • Although there are side effects, none of the side effects are medically serious.

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What are some reasons patients hesitate or wait to use DMT medications?

  • On average, DMTs decrease disease activity by about 1/3. Each patient must balance the 1/3 slowing of the disease with the inconvenience of using these treatments.
  • Though the majority of patients develop some impairment with time, about 15% have very little or no disability even after 20 years. Some patients do not use these medications, hoping they will be one of the fortunate ones. However, there is no way to predict which patients will remain without disability.
  • The medications are expensive. They are generally covered by the VA and insurance, but some insurance plans have high medication co-payments. Also, insurance plans may refuse to cover the cost for some types of MS (such as primary progressive).
  • These medications are given by injection. The needles are small and usually cause little pain. The greatest barrier to using them is the inconvenience of injections rather than the pain.
  • Though the side effects are not medically serious, they can be uncomfortable.

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Serial MRI Scans

After weighing these factors, most patients will choose to proceed with treatment rather than risk an increased rate of disease progression. In those choosing to wait before proceeding with DMTs, serial MRI scans may provide evidence of asymptomatic progression and increased risk.

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Last Updated: November 2009