Patients with late-onset multiple sclerosis (LOMS) should be managed differently than patients with adult-onset (AO) MS. Prof. Fredrik Piehl from the Karolinska University Hospital, in Sweden, MD, PhD, talked about various treatment-related aspects that should be taken into consideration for the management of this specific group of patients.

“We see less inflammatory disease activity and fewer relapses in patients with LOMS than in patients with AOMS,” said Prof. Piehl. “However, the consequences of a relapse may be worse in patients with LOMS and LOMS is associated with more evident neurodegeneration.”

Differences between older and younger patients with MS can also be seen in the benefit of disease-modifying treatments. The benefit from treatment in terms of relapse risk and disability progression appears to be less in patients older than 40 years versus patients younger than 40 years. From 53 years of age, there may be no benefit at all, a meta-analysis indicated. “On the other hand, with older age, the therapeutic risk increases due to co-morbidities and perhaps more severe treatment-related AEs,” added Prof. Piehl. Especially with anti-CD20 therapies, the risk for hospital-treated infections increases with longer treatment duration. “Moreover, infections are more likely to have an impact on disability progression if a patient is older,” according to Prof. Piehl.

Results from the DISCOMS study suggested that it is probably safe to de-escalate therapy in a population of patients with a median age of 62 years. However, in patients 50–55 years of age it may not be safe to de-escalate therapy, findings from the DOT-MS trial revealed. “The authors observed a significantly increased MRI activity in patients who discontinued therapy versus those who stayed on therapy,” clarified Prof. Piehl. He further explained that the de-escalation strategy depends on the disease-modifying therapy at hand. “With anti-CD20 therapies, there is no substantial risk for rebound after discontinuation, whereas natalizumab comes with an increased risk for rebound if this drug is stopped.”

Prof. Piehl emphasized that the initiation of a disease-modifying treatment at an older age should be based on inflammatory disease activity and not just on chronological age cut-offs. Finally, he mentioned that the choice of therapy should be based on an individualized benefit-risk analysis, taking inflammatory activity and co-existing risk factors into account.

Medical writing support was provided by Robert van den Heuvel.

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