2022 年 39 巻 3 号 p. 268-272
Recent progress in disease modifying drugs (DMDs) for multiple sclerosis (MS) has been remarkable, with anti–monoclonal antibody therapies covered by insurance in Japan since January 2022. DMDs in current use include interferon (IFN) β1b and β1a, glatiramer acetate (GA), fingolimod (FTY), natalizumab, dimethyl fumarate (DMF), siponimod, and ofatumumab.
When should DMDs be initiated for patients with MS? Treatment should be started and continued from the time of diagnosis. To maintain adherence to DMD at this early stage, oral FTY and DMF drugs can be added to IFNβ and GA injections with the aim of improving patients' quality of life in areas such as school attendance, employment, pregnancy/childbirth, and family life.
Early diagnosis and treatment of relapsing–remitting (RR) MS can delay the transition to secondary progressive (SP) MS. As yet, there are no clear diagnostic criteria for SPMS but its treatment is possible, and siponimod and ofatumumab are covered by insurance in Japan for the purposes of “preventing advance to SPMS and suppressing progression of disability”. However, when and how to identify SPMS remains problematic in the absence of specific diagnostic criteria.
What clinical characteristics identify the MS patients most likely to benefit from DMDs? Although no consensus has been established, poor prognostic factors of MS have been attracting attention as an index of patient selection for DMDs. It is recomend that patients with “low” prognostic factors for RRMS should start with IFNβ, GA, or DMF ; and that those with “high” prognostic factors should start with FTY, natalizumab, or ofatumumab, which are high–efficacy DMDs. However, high–efficacy DMDs increase the risk of progressive multifocal leukoencephalopathy. In addition, it is necessary to consider COVID–19 and susceptibility to infection.
The number of treatment options for MS is increasing, and treatment management is required that takes into consideration the risks and benefits of each DMD as well as the disease activity and life events of individual patients.
