Page 5 - Gulf Consensus
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IDENTIFYING AND MANAGING SUBOPTIMAL RESPONSE IN RRMS






        There is no evidence base from randomized
        clinical trials for defining suboptimal response            The consensus definitions of suboptimal response
        and subsequent decision of switching/escalation             and actions recommended are shown in Table 2.
        from second-line therapies.


            Table 2. Actions recommended for specific manifestations of suboptimal treatment response.


               Suboptimal response after                       Action recommended
               1 year of 1  line treatment
                         st
               A single MRI lesion in a strategic location     This may prompt scheduling further follow-up
               (spinal cord, cerebellum, brain stem) or ≥3     MRI at 6 months or lateral switching to other
               MRI lesions in non-strategic locations.         DMD (with different mechanism of action)
               or                                              but this depends on the overall presentation
               Single relapse (non-disabling), without EDSS    (consider a higher efficacy DMD)
               progression  or MRI activity.
                         a
               MRI progression + relapse
               or                                              Switching DMD treatment
               EDSS progression + relapse

            a Usually defined as progression by 1 point for EDSS <5, or 0.5 points if EDSS ≥5.





        SWITCHING OF THERAPY





           A switch of DMD due to a tolerability or patient preference issue may be achieved via a new DMD of similar
           efficacy, but a different mechanism (a ‘lateral switch’).



           The mechanisms of action, pharmacokinetics, and pharmacodynamics of a DMD may provide important
           information relating to the need or otherwise to switch a treatment.




           For alemtuzumab and cladribine tablets, it is recommended to finish the 2-year course even if a relapse
           occurs during the first year of treatment before judging the efficacy of such immune reconstitution DMDs.



           Other factors such as long-term safety, monitoring burden, lifestyle/compliance, and pregnancy are
           important to consider when initiating/escalating DMDs.






                            Alroughani R, Inshasi J, Al-Asmi A, et al. Expert consensus from the Arabian Gulf on selecting
        REFERENCE:          disease-modifying treatment for people with multiple sclerosis according to disease activity.
                            Postgraduate Medicine, DOI: 10.1080/00325481.2020.1734394
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