Treatment Algorithm For Multiple Sclerosis Disease Modifying Therapies
Treatment Algorithm For Multiple Sclerosis Disease Modifying Therapies
Treatment Algorithm For Multiple Sclerosis Disease Modifying Therapies
Multiple Sclerosis
Disease-modifying
Therapies
NHS England Reference: 170079ALG
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Treatment Algorithm for Multiple Sclerosis Disease-modifying Therapies 4 September 2018
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Scolding N, Barnes D, Cader S, Chataway J, Chaudhuri A, Coles A, Giovannoni G, Miller D, Rashid W, Schmierer K,
Shehu A, Silber E, Young C, Zajicek J. Association of British Neurologists: revised (2015) guidelines for prescribing
disease-modifying treatments in multiple sclerosis. Pract Neurol. 2015 Aug;15(4):273-9
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Treatment Algorithm for Multiple Sclerosis Disease-modifying Therapies 4 September 2018
3. Definitions
The definitions below are taken from the Clinical Commissioning Policy for the use of Disease
Modifying Therapies for patients with Multiple Sclerosis, published by NHS England in 2014.
They represent useful explanations of terms used by the regulatory authorities, which were
translated into NICE approvals. However, there is no difference in biological significance between
relapses causing differing varying degrees of disability; all indicate disease activity.
Clinically significant relapse: All relapses are clinically significant, but in usual practice
relapses contributing to the eligibility for Disease Modifying Therapies are:
Any motor relapse
Any brainstem relapse
A sensory relapse if it leads to functional impairment
Relapse leading to sphincter dysfunction
Optic neuritis
Intrusive pain lasting more than 48 hours.
Disabling relapse: A disabling relapse is defined as any relapse which fulfils one or more of the
following criteria:
Affects the patient’s social life or occupation, or is otherwise considered disabling by the
patient
Affects the patient’s activities of daily living as assessed by an appropriate method
Affects motor or sensory function sufficiently to impair the capacity or reserve to care for
themselves or others
Needs treatment/hospital admission.
Highly active disease: Patients with an unchanged or increased relapse rate or ongoing severe
relapses compared with the previous year despite treatment with beta interferon.2 The NICE
appraisal on cladribine offers a slightly different definition: “defined as 1 relapse in the previous
year and magnetic resonance imaging (MRI) evidence of disease activity.” [From NICE Technical
Advice (TA) 254: Fingolimod for the treatment of highly active relapsing- remitting multiple
sclerosis]
Rapidly evolving severe (RES) relapsing–remitting disease: Defined by two or more
disabling relapses in one year and one or more gadolinium-enhancing lesions on brain MRI or a
significant increase in T2 lesion load compared with a previous MRI. [From NICE Technical
Advice (TA) 127: Natalizumab for the treatment of adults with highly active relapsing-remitting
multiple sclerosis]
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We note that later definitions of Highly Active Disease incorporate the requirement for a certain number of T2
lesions. We do not think this is necessary.
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Treatment Algorithm for Multiple Sclerosis Disease-modifying Therapies 4 September 2018
may transiently have disability greater than EDSS 7.0; if they recover to a sustained
EDSS less than 7.0, they are eligible for DMTs)
No evidence of non-relapsing progressive multiple sclerosis.
It is important that, at the start of treatment, the patient understands that treatment may be
stopped if it is ineffective, intolerable adverse events arise, the patient becomes pregnant or they
develop progressive disease or fixed disability above EDSS 6.5.
7. Inappropriate DMTs
Corticosteroids and plasma exchange have roles in the treatment of acute relapses of
multiple sclerosis, but do not have long-term disease-modifying efficacy.
Intravenous immunoglobulin has no place in the treatment of multiple sclerosis.
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Treatment Algorithm for Multiple Sclerosis Disease-modifying Therapies 4 September 2018
Notes:
1. Trials of first-line therapies in people with the original definition of Clinically Isolated
Syndrome (CIS) at high risk of conversion have NOT shown a convincing long-term effect
on the accumulation of disability. In 2018, NICE concluded that it was “unable to make
recommendations for treating clinically isolated syndrome because the diagnostic criteria
for multiple sclerosis and clinically isolated syndrome have changed and the treatment
pathway has evolved”. These new diagnostic criteria are the 2010 and 2017 Mc Donald
criteria.
2. Under 2018 NICE guidance: interferon beta 1a and glatiramer acetate can be offered to
people with “relapsing-remitting” multiple sclerosis under the new diagnostic criteria.
3. In exceptional circumstances, where clinical or radiological markers indicate a poor
prognosis for rapidly developing permanent disability, alemtuzumab may be considered
after a single clinical episode with MRI activity. Physicians and patients should weigh up
the considerable risks and burden of monitoring associated with this drug, against the
potential benefit.
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Treatment Algorithm for Multiple Sclerosis Disease-modifying Therapies 4 September 2018
Alemtuzumab [note 8]
Rapidly evolving severe MS Cladribine [note 8]
Natalizumab
Notes:
4. For RRMS (that is not rapidly evolving severe (RES) RRMS), beta-interferon, glatiramer
acetate and teriflunomide are effective and safe.
5. There is some evidence that dimethyl fumarate may be more effective at suppressing
relapses than beta-interferon, glatiramer and teriflunomide.
6. The clinical commissioning policy for the use of Disease Modifying Therapies for patients
with Multiple Sclerosis, published by NHS England in 2014 allowed the use of beta-
interferon in “patients with only a single major relapse in the preceding two years, but
combined with MRI evidence of continuing disease activity”. The NICE 2018 guidance
suggests glatiramer acetate may also be used in this context.
7. For RRMS (that is not RES), alemtuzumab is an option that may be considered, but we
note it is considerably more high-risk than the other options. It should be used only when
the patient and MS specialists accept the significant risks and burden of monitoring.
8. Alemtuzumab and cladribine may be considered - by some patients and physicians - a
safer option than natalizumab when John Cunningham (JC) virus serology is high-index
positive.
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Treatment Algorithm for Multiple Sclerosis Disease-modifying Therapies 4 September 2018
Alemtuzumab
Alemtuzumab Cladribine
Rapidly evolving severe MS Cladribine Fingolimod [note 10]
Natalizumab Natalizumab
Notes:
9. If a patient satisfies the eligibility criteria for a first-line therapy, and then is relapse-free on
a drug to which he/she becomes intolerant, they may be switched to another DMT even
though their relapses may now fall outside the eligibility window.
10. NHS England 2014 policy states that fingolimod can be used as an alternative to
natalizumab for those patients receiving natalizumab who are at high risk of developing
progressive multifocal leukoencephalopathy (PML) as defined by the following:
(i) JCV exposure indicated by anti-JCV antibody positive status,
(ii) Receiving an immunosuppressant prior to receiving natalizumab, or
(iii) Natalizumab treatment duration of >2 years. If patients develop a severe adverse
effect to natalizumab (e.g. anaphylaxis), and they have not previously received
fingolimod, then it may be appropriate to use fingolimod.
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Treatment Algorithm for Multiple Sclerosis Disease-modifying Therapies 4 September 2018
Alemtuzumab Alemtuzumab
Rapidly evolving Cladribine Cladribine
severe MS Natalizumab Natalizumab
11. Definition of disease activity: treatment failure may be indicated by either clinical or
radiological relapse-related changes, after significant exposure to the treating drug, with
changes indicating a poor prognosis for future disability. For instance, alemtuzumab is
specifically licensed for “active disease defined by clinical or imaging features”.
12. For cladribine, NICE specifically defined treatment failure as “1 relapse in the previous
year and MRI evidence of disease activity.”
13. For fingolimod: under previous guidance, fingolimod may be given if patients have an
unchanged or increased relapse rate or ongoing severe relapses compared with the
previous year despite treatment with beta interferon or glatiramer acetate. This is now
extended to include disease activity on teriflunomide and dimethyl fumarate (DMF).
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Treatment Algorithm for Multiple Sclerosis Disease-modifying Therapies 4 September 2018
Alemtuzumab
If the patient
Natalizumab [note 15]
develops RES
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Treatment Algorithm for Multiple Sclerosis Disease-modifying Therapies 4 September 2018
interferon-1a AVONEX is indicated for the treatment [ID1809 NICE] All of the following criteria must be
of: I(i) Patients diagnosed with met. The patient: (i) has had at least
relapsing multiple sclerosis (MS). In Interferon beta-1a [AVONEX and 2 clinically significant relapses in
clinical trials, this was characterised REBIF] is recommended as an previous 2 years; (ii) is able to walk
by two or more acute exacerbations option for treating multiple 10m or more**; (iii) is not pregnant or
(relapses) in the previous three years sclerosis, only if the person has attempting conception.
without evidence of continuous relapsing–remitting multiple
progression between relapses; sclerosis. Neurologists may, in certain other
AVONEX slows the progression of circumstances where the evidence
disability and decreases the frequency for efficacy is less secure, also
of relapses; (ii) Patients with a single consider advising treatment after
demyelinating event with an active discussion with the patient
inflammatory process, if it is severe concerning the risks and benefits.
enough to warrant treatment with For example;: (i) Patients within 12
intravenous corticosteroids, if months of a clinically significant
alternative diagnoses have been clinically isolated syndrome when
excluded, and if they are determined MRI evidence predicts a high
to be at high risk of developing likelihood of recurrent episodes (i.e.
clinically definite multiple sclerosis development of MS); (ii) patients with
(see section 5.1). only a single major relapse in the
preceding two years, but combined
REBIF is indicated for the treatment of with MRI evidence of continuing
relapsing multiple sclerosis. In clinical disease activity (i.e. meet the revised
trials, this was characterised by two or McDonald criteria for MS); (iii)
more acute exacerbations in the individuals aged less than 18 with
previous two years. NICE is not currently in a position relapsing remitting MS
to make recommendations on
PLEGRIDY is indicated in adult ** For patients who can walk
PLEGRIDY pegylated interferon
patients for the treatment of relapsing between 10 and 99 m (aided or
beta-1a.
remitting multiple sclerosis unaided, EDSS 6.0 to 6.5), treatment
with DMTs is permitted bur
recommended less strongly than for
patients able to walk more than
100m unaided (EDSS 5.5 or less).
interferon -1b BETAFERON is indicated for the BETAFERON is not As per interferon-1a guidance, but
treatment of (i) patients with a single recommended also permits the use of interferon-1b
demyelinating event with an active in relapsing-progressive disease.
inflammatory process, if it is severe
enough to warrant treatment with
intravenous corticosteroids, if
alternative diagnoses have been
excluded, and if they are determined
to be at high risk of developing
clinically definite multiple sclerosis; (ii)
patients with relapsing-remitting
multiple sclerosis and two or more
relapses within the last two years. (iii)
patients with secondary progressive
multiple sclerosis with active disease,
evidenced by relapses.
EXTAVIA is indicated for the treatment
of (i) Patients with a single EXTAVIA is recommended as an
demyelinating event with an active option for treating multiple
inflammatory process, if it is severe sclerosis, only if the person has
enough to warrant treatment with relapsing–remitting multiple
intravenous corticosteroids, if sclerosis and has had 2 or more
alternative diagnoses have been relapses within the last 2 years or
excluded, and if they are determined the person has secondary
to be at high risk of developing progressive multiple sclerosis with
clinically definite multiple sclerosis; (ii) continuing relapses
Patients with relapsing remitting
multiple sclerosis and two or more
relapses within the last two years; (iii)
Patients with secondary progressive
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Treatment Algorithm for Multiple Sclerosis Disease-modifying Therapies 4 September 2018
Glatiramer COPAXONE and BRABIO are Glatiramer acetate is As per interferon-beta guidance, but
acetate indicated for for the treatment of recommended as an option for must be able to walk 100m or more
relapsing forms of multiple sclerosis treating multiple sclerosis, only if
(MS) (see section 5.1 for important the person has relapsing–remitting
information on the population for multiple sclerosis. (N.b.
which efficacy has been established). “Stakeholders consider glatiramer
Neither are indicated in primary or acetate to be the safest drug for
secondary progressive MS anyone who is planning to become
pregnant”.)
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Treatment Algorithm for Multiple Sclerosis Disease-modifying Therapies 4 September 2018
those who have failed to respond to a lesions on brain magnetic in T2 lesion load
full and adequate course (normally at resonance imaging (MRI) or a compared with previous
least one year of treatment) of beta- significant increase in T2 lesion MRI unless comparator
interferon or glatiramer acetate. load compared with a previous MRI is unavailable or
Patients should have had at least 1 MRI assessment of gadolinium-
relapse in the previous year while on enhancement is unreliable
therapy, and have at least 9 as the patient is treated
T2‑hyperintense lesions in cranial with steroids at around the
Magnetic Resonance Image (MRI) or time of scan.
at least 1 Gadolinium‑enhancing has had no previous
lesion. A “non-responder” could also disease modifying therapy
be defined as a patient with an OR is receiving treatment
unchanged or increased relapse rate with beta interferon and
or ongoing severe relapses, as does not meet the agreed
compared to the previous year. stopping criteria.
*As per NICE Technology Appraisal
Guidance 127 patients with high
or disease activity taking beta interferon
or glatiramer acetate but do not fulfil
the RES criteria will not be routinely
Adult Patients aged 18 years and over funded for natalizumab.
with rapidly evolving severe relapsing
remitting multiple sclerosis defined by
2 or more disabling relapses in one
year, and with 1 or more Gadolinium
enhancing lesions on brain MRI or a
significant increase in T2 lesion load
as compared to a previous recent MRI
alemtuzumab LEMTRADA is indicated for adult [TA312] Published date: 28 May NHS England will fund up to three
patients with relapsing remitting 2014: Alemtuzumab is cycles of alemtuzumab. Any furteh4r
multiple sclerosis (RRMS) with active recommended as an option, within cycles would need to be approved by
disease defined by clinical or imaging its marketing authorisation, for NICE under a review of TA312.
features treating adults with active
relapsing–remitting multiple
sclerosis.
cladribine MAVENCLAD is indicated for the Cladribine tablets are
treatment of adult patients with highly recommended as an option for
active relapsing multiple sclerosis treating highly active multiple
(MS) as defined by clinical or imaging sclerosis in adults, only if the
features person has: (1) rapidly evolving
severe relapsing–remitting
multiple sclerosis, that is, at least
2 relapses in the previous year
and at least 1 T1 gadolinium-
enhancing lesion at baseline MRI
or (2) 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.
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Treatment Algorithm for Multiple Sclerosis Disease-modifying Therapies 4 September 2018
Members of the MS Advisory Group of the ABN, who commented on the algorithm
Waqar Rashid Neurologist
Robert Brenner Neurologist
Adnan Al-Araji Neurologist
Bruno Gran Neurologist
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