Multiple Sclerosis Centers of Excellence
Making the Decision to Use Disease Modifying Therapies for Multiple Sclerosis
James Bowen, MD
All people with MS should discuss taking a disease modifying therapy (DMT) with their MS provider. When offered, most people with MS choose to take them. Fortunately, we now have over a dozen different DMTs that slow the course of MS. These medications have all been proven to benefit people with MS in well-designed large studies. Based on the results of these studies, the MS Coalition states that starting DMT treatment should occur: “as soon as possible when a person has been diagnosed with relapsing or primary progressive MS, regardless of age”. Because DMTs, like any medication, comes with risks, people with MS must decide for themselves, with the help of their doctors, whether they wish to start, stop, or continue use of these medications.
MS DMTs are the only medications proven to slow the disease. After 20 years, 15-20% of untreated people with MS 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 people with MS believe they do not have enough attacks to warrant use of DMTs. However, people with MS are not aware of most MS attacks. A very conservative estimate is that people with MS 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 people with MS wait to see if they will become more disabled before using DMTs. However, these drugs do not reverse damage; they decrease future damage. Our advice is to start DMTs before more damage occurs.
- There is evidence that people with MS using DMTs early in the disease leads to better long-term responses than those treated later in the disease. This is true even after the first attack, called Clinically Isolated Syndrome, and several DMTs are FDA-approved in this early stage of disease.
DMTs vary widely in their ability to slow the course of the disease, in their risks, and their side effects. In addition, there are factors like cost, how the DMT is taken (by mouth, injection, infusion), other health conditions that could be affected by a certain DMT, and personal tolerance for risk, among others that factor into the decision to take a DMT. Each person with MS must consider both the benefits and the risks when choosing which DMT to take. MS practitioners, familiar with DMTs can explain the risk-benefit equation to help people with MS make these decisions.
The decision to start a DMT is not a one-time event. The decision can be revisited at any time, and should when disability worsens, there are new clinical attacks, there are new lesions on the MRI, or new therapies become available. Likewise, once on a DMT, continuation of that therapy can also be revisited for the same reasons as above as well for reasons of side effects or serious reactions. MS providers monitor people with MS at every visit for how well they tolerate their DMT, screen for any serious risks, evaluate MS disability with the neurological exam and periodic MRIs, and help guide their patients with decision about DMTs.
