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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