Mark S. Freedman, MD, MSc; Patricia K. Coyle, MD


November 12, 2013

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A Cluttered Medicine Cabinet

Mark S. Freedman, MD, MSc: Hello. I am Dr. Mark Freedman, Professor of Neurology at the University of Ottawa and the senior scientist at the Ottawa Hospital Research Institute in Ottawa, Ontario, Canada, speaking to you from the 29th Congress of the European Committee for Treatment and Research in Multiple Sclerosis (ECTRIMS) in beautiful Copenhagen, Denmark. I am here today with Patricia Coyle, Vice Chair of Clinical Affairs and Director of the MS Comprehensive Care Center at Stony Brook University in Stony Brook, New York. Welcome, Pat.

Patricia K. Coyle, MD: Thank you, Mark.

Dr. Freedman: It's a great meeting. There are many new developments. Could you tell us about some of the new medications that have been approved in the past few months throughout the world, and what this means for multiple sclerosis treatment?

Dr. Coyle: Itis becoming very cluttered. Alemtuzumab has just been approved in the European Union and is likely to be approved in the United States in the next couple of months. We also have 2 new oral agents that were approved within the past year in the United States: teriflunomide and dimethyl fumarate. We are learning more about these agents and thinking about how we are going to use them. They are quite different.

Dr. Freedman: Let's start with the 2 new orals. Where are you placing them in the cascade of treatments? Are these first-line agents?

Dr. Coyle: They are first-line agents but they are a little bit different. Teriflunomide has a category X pregnancy rating, so you might favor that drug in patients who are not interested in pregnancy. It is an extremely well-tolerated agent; it has the perception of not being dynamite in reducing relapses, but it is associated with some very good disability and MRI data. Dimethyl fumarate came on the market with a big bang, has good data, but is a little bit dicier with respect to the gastrointestinal side effects, which are a little more than we expected. You need to play around with it and prepare patients for that.

Dr. Freedman: And we now have fingolimod. We are looking at many congeners of fingolimod with other sphingosine 1 phosphate (S1P) receptor agonists not yet on the market. Have we learned anything more about fingolimod now that it has been out there for a year or two?

Dr. Coyle: We have refined our knowledge about the cardiac adverse events, and the manufacturer has made a label change that makes it somewhat more restrictive with respect to medical history, comorbid conditions, and awareness of how drugs can interact to cause conduction issues. We are more careful about using that drug in the small group of patients with multiple sclerosis who have significant cardiac disease.


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