Loading ...

TOPLINE:

Discontinuing high-efficacy therapies (HETs) that affect immune cell trafficking such as natalizumab and fingolimod is associated with a significant increased relapse risk in older adults with multiple sclerosis (MS). However, stopping HETs that deplete B cells, such as anti-CD20 therapy, carries no relapse risk.

METHODOLOGY:

• The observational cohort study drew on data on 1620 patients (72.5% female; mean age, 55 years) from 38 referral centers in the French MS Registry.
• The study included 1452 patients in the HET continuation group and 168 in the discontinuation group.
• A total of 154 patients in each group were paired using propensity matching for age, sex, disease phenotype, disability, treatment of interest, and time since last inflammatory activity.
• Mean follow-up after propensity matching was 2.5 years.

TAKEAWAY:

• Time to first relapse was four times shorter in the HET discontinuation group than in the HET continuation group (hazard ratio [HR], 4.1; P < .001).
• Increased probability of relapse was significant in patients with relapsing-remitting MS (HR, 4.3; P < .001) but not in patients with secondary progressive MS.
• There were differences between the various HETs with regard to time to first relapse after discontinuation with natalizumab (HR, 7.2; P = .001) and fingolimod (HR, 4.5; P = .02).
• There was no significantly increased risk for relapse with discontinuation of anti-CD20 therapy.

IN PRACTICE:

Earlier studies reported an increased relapse risk with HET discontinuation in younger patients, but data on discontinuation among older adults were lacking. "Our study confirmed these risks in an older population, suggesting that the mechanism of action of the interrupted treatment is an important factor, independent of patient age," the study authors wrote.

SOURCE:

Anne Kerbrat, MD, PhD, of the Department of Neurology, University Hospital of Rennes, Rennes, France, was the corresponding and senior author of the study. It was published online on March 25 in JAMA Neurology.

LIMITATIONS:

Precautions were taken to ensure that HET discontinuation did not correspond to a treatment switch, but that type of information is difficult to obtain in a registry-based study, along with the limited availability of MRI data. Level of evidence is lower than that of a randomized clinical trial. The risk for relapse decreased linearly with age (−7% per year), but the researchers were unable to reliably estimate the risks associated with stopping these treatments after age 60 years and so were unable determine whether the risk becomes lower at a certain age.

DISCLOSURES:

Data collection was supported by a grant provided by the French State and handled by the Agence Nationale de la Recherche within the framework of the France 2030 program Observatoire Français de la Sclérose en Plaques. Kerbrat reported no relevant financial relationships. The other authors' disclosures were listed in the original paper.