Disease modifying therapy in relapsing-remitting MS

Disease modifying therapy in relapsing-remitting multiple sclerosis has two aims:

• reduction in the frequency and severity of attacks
• prevention of the accumulated disability associated with transition to secondary progressive multiple sclerosis

Effective therapies are immune modulators and include:

• interferon beta-1a
• interferon beta-1b
• glatiramer acetate
• azathioprine

NICE

• have recommended that natalizumab is an option for the treatment only of rapidly evolving severe relapsing - remitting multiple sclerosis (1)
  
  
• interferon beta-1a is recommended as an option for treating multiple sclerosis (2), only if:
  • the person has relapsing-remitting multiple sclerosis and
  • the companies provide it according to commercial arrangements
    
    
• interferon beta-1b (Extavia) is recommended as an option for treating multiple sclerosis (2), only if:
  • the person has relapsing-remitting multiple sclerosis and
  • has had 2 or more relapses within the last 2 years or
  • the person has secondary progressive multiple sclerosis with continuing relapses and
  • the company provides it according to the commercial arrangement
    
    
• glatiramer acetate is recommended as an option for treating multiple sclerosis (2), only if:
  • the person has relapsing-remitting multiple sclerosis
  • and the company provides it according to the commercial arrangement
    
    
• have recommended Fingolimod is recommended as an option for the treatment of highly active relapsing-remitting multiple sclerosis in adults (3)
  
  
• have recommended Teriflunomide for treating adults with active relapsing-remitting multiple sclerosis (normally defined as 2 clinically significant relapses in the previous 2 years) (4)
  • only if they do not have highly active or rapidly evolving severe relapsing-remitting multiple sclerosis
    
    
• have recommended Dimethyl fumarate as an option for treating adults with active relapsing-remitting multiple sclerosis (5) only if :
  • they do not have highly active or rapidly evolving severe relapsing-remitting multiple sclerosis and
  • the manufacturer provides dimethyl fumarate with the discount agreed in the patient access scheme
    
    
• cladribine is recommended as an option for treating highly active multiple sclerosis in adults, only if the person has (7):
  • rapidly evolving severe relapsing - remitting multiple sclerosis, that is with at least:
    • 2 relapses in the previous year and
    • 1 T1 gadolinium-enhancing lesion at baseline MRI or a significant increase in T2-lesion load compared with a previous MRI, or
  • relapsing - remitting multiple sclerosis that has responded inadequately to treatment with disease-modifying therapy, defined as 1 relapse in the previous year and MRI
    evidence of disease activity
    
    
• ofatumumab is recommended as an option for treating relapsing-remitting multiple sclerosis in adults with active disease defined by clinical or imaging features
  • is a human monoclonal antibody that binds selectively to CD20
  • although other currently available monoclonal antibody therapies for RMS are administered by intravenous infusion (e.g., alemtuzumab, natalizumab and ocrelizumab), ofatumumab is administered subcutaneously

Notes:

• diemthyl fumaratederives from fumaric acid, promotes anti-inflammatory activity and can inhibit expression of pro-inflammatory cytokines and adhesion molecules
  • dimethyl fumarate has a UK marketing authorisation for 'the treatment of adult patients with relapsing-remitting multiple sclerosis'.

Reference:

1. NICE (August 2007). Natalizumab for the treatment of adults with highly active relapsing-remitting multiple sclerosis.
2. NICE (June 2018). Beta interferons and glatiramer acetate for treating multiple sclerosis
3. NICE (April 2012). Fingolimod for the treatment of highly active relapsing-remitting multiple sclerosis
4. NICE (January 2014). Teriflunomide for treating relapsing-remitting multiple sclerosis
5. NICE (August 2014). Dimethyl fumarate for treating relapsing-remitting multiple sclerosis
6. NICE (November 2019). Multiple sclerosis in adults: management
7. NICE (December 2019). Cladribine for treating relapsing - remitting multiple sclerosis
8. NICE (May 2021). Ofatumumab for treating relapsing multiple sclerosis