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Cat: What DMTs are most effective in preventing brain atrophy?

Professor Gavin Giovannoni, Neurologist: So the, I think you’re referring to the accelerated brain volume loss that occurs in people with the disease, because as you know, our brains all shrink after the age of about 35 and people with MS’s brains shrink between two and seven times more quickly. And I think it’s got to do with a treatment principle, because all treatments, if they’re effective, will normalise or pseudo-normalise, a term I use, we can’t be a hundred per cent sure it’s normal. And so it’s making you free of activity. In other words, suppressing all inflammatory activity. And we call that no evident disease activity. And the proportion of people that are made NEDA – no evident disease activity – depends on how effective the drug is. The more effective the therapy, the bigger the proportion. So it’s horses for courses, some people go on to some of the old injectable treatments and become NEDA and do very well, but that’s a small number. And so, as soon as you move on to the intermediate therapies the number goes up from, say, 20% in five years to 40% and as soon as you get to the more effective therapies, the majority of people will be on a therapy that suppresses all inflammation, or the majority of it, and slow down their brain volume or normalise it.

So it’s like a, it’s a chance you’ve got to take. Which strategy, do you want to go with the safer first line therapies first, or do you want to go with the one that gives you the greatest chance of having it normalised in the beginning. And the thing about the more effective therapies, they come with more risks, so it’s a bit of a risk-benefit balance. But the message I always tell my patients is that if they do go with the more or less effective ones, we need to monitor them and if they’re not responding then we need to move them to more effective therapies to achieve that same aim. We’re trying to get them to the level of therapy they need for their disease to render them NEDA and then hopefully normalise brain volume loss. So I haven’t answered the question, because all drugs can do it, it’s just that the more effective drugs are much better at doing it than the less effective drugs, on average.

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