The so-called “Swedish treatment strategy” encourages the use of stronger, more effective DMTs in people with RRMS earlier in the course of the disease. The idea is that earlier initiation with these more effective drugs slows the rate of disability worsening, as measured on a standardized scale. RELATED: MS Medications
Balancing Drug Efficacy With Safety and Side Effects
In the past, some neurologists have held off on using these more effective drugs in some people with MS due to their side effects. Instead, they’ve opted to initiate treatment with less effective, but safer, drugs at lower doses and increase the doses or switch to stronger therapies, as needed, based on disease activity, or relapses. “Our study supports the growing body of evidence that early treatment with highly efficacious drugs is advantageous, at least over the older treatment escalation [approach],” says study coauthor Tim Spelman, MD, PhD, a professor of clinical neuroscience at Karolinska Institute in Stockholm.
Study Compares Swedish With Danish MS Treatment Strategy
The study compared the effectiveness of MS treatment in Sweden, where neurologists have the “flexibility” to start people with RRMS on highly effective DMTs, to that in Denmark, where the treatment escalation strategy remains standard, Dr. Spelman says. To do so, Spelman and his colleagues collected medical data on 2,700 people with RRMS in Sweden and 2,161 in Denmark. They compared “disability worsening” after six months of MS treatment in study participants, based on Expanded Disability Status Scale (EDSS) scores. The EDSS is a widely used tool for quantifying physical disability caused by MS. Individuals who had started a DMT between 2013 and 2016 were included in the analysis, and their progress over time was noted. Among the Swedish participants, roughly 35 percent started treatment with a highly effective DMT compared with just under 8 percent of those in Denmark.
Taking a Highly Effective DMT Reduces Rate of Disability Worsening
The Swedish participants who were started on a highly effective DMT saw a 29 percent larger reduction in the rate of disability worsening after six months of treatment than the Danish participants who were managed using the treatment escalation approach, Spelman and his colleagues report. In addition, the participants started on a highly effective DMT experienced a 24 percent reduction in the rate of reaching an EDSS score of 3, compared with the Danish participants. Those started on a highly effective DMT took more than two years to reach an EDSS score of 3, while those on treatment escalation took a little more than 18 months. Furthermore, Swedish participants started on highly effective DMT took nearly four years to reach an EDSS score of 4, while the Danish participants did so more than a year earlier. Meanwhile, Swedish participants were 22 percent less likely to discontinue treatment and 12 percent less likely to switch treatments, due to lack of results, than their Danish counterparts, the researchers say.
Differing National Strategies
In Sweden in recent years, the monoclonal antibody Rituxan (rituximab), which is considered a high-efficacy treatment, is increasingly being used as a first-line treatment for RRMS. This is in spite of Rituxan not being approved treat MS in Sweden. As it is in the United States and elsewhere in the world, Rituxan must be administered off-label in Sweden. Conversely, in Denmark, 42 percent of the study participants were started on Aubagio (teriflunomide), which was the most frequent first-line treatment, followed by interferon beta-1a, in 30 percent, according to Spelman and his colleagues. Both Aubagio and interferon beta-1a are considered to have the lowest efficacy of the MS therapies, according to UpToDate.
How the Results Can Be Applied Elsewhere in the World
“Even though other healthcare settings and countries are certainly more diverse in terms of patient population [than Sweden and Denmark], we would argue that by selecting two very similar and homogenous national settings, we were able to more directly attribute differences in clinical outcome to the national treatment strategy itself,” Spelman notes. “This in turn provides additional real-world evidence supporting early initiation of highly efficacious therapy across other settings outside of Scandinavia,” he concludes.
