Key Takeaways
1. Neurofilament light chain is emerging as a useful, though not yet mainstream, biomarker in MS. Rather than a single value, tracking neurofilament light chain over time alongside clinical status may help identify subclinical disease progression, particularly in patients without clear relapses.
2. DMT discontinuation in older, stable patients remains individualized, with most practices starting the conversation around 60 to 65 years of age. Clinicians weigh 10-year clinical and radiographic stability, and some patients opt for a gradual step-down in dosing frequency or a switch to a lower-efficacy agent rather than outright discontinuation.
3. New pregnancy and breastfeeding safety data continue to support anti-CD20 therapies as a preferred family planning strategy in MS. A 10-year, 5000-pregnancy dataset on ocrelizumab, reassuring malformation data on ofatumumab, and early breastmilk transfer data on ublituximab are strengthening patient counseling conversations around conception, pregnancy, and postpartum DMT resumption.
In this episode of Mind the Meds, host Erica Marini, PharmD, MS, BCPS, welcomes Jenelle Hall Montgomery, PharmD, BCACP, CPP, a clinical pharmacist practitioner with Duke Neurological Disorders Clinic at Duke University Hospital, to discuss highlights from the Consortium of Multiple Sclerosis Centers (CMSC) Annual Meeting in Charlotte, North Carolina, where Montgomery was recognized as a Giant of Multiple Sclerosis. Before the CMSC discussion, Marini runs through a roundup of recent neurology news, including approval of at-home initiation dosing for lecanemab-irmb (Leqembi; Eisai, Biogen), fast track designation for remlifanserin (Acadia Pharmaceuticals) in Alzheimer disease psychosis, approval of the oral PCSK9 inhibitor enlicitide (Lipfendra; Merck), and phase 3 data on tavapadon (AbbVie) for Parkinson disease showing a lower rate of impulse control disorders than traditional dopamine agonists.
The pharmacists then turn to CMSC sessions on off-label and evolving areas of MS care. They discuss growing interest in neurofilament light chain as a biomarker for tracking subclinical disease progression over time, along with the ongoing debate over when it is safe to discontinue disease-modifying therapy (DMT) in older, stable patients. Both note their practices generally begin this conversation around 60 to 65 years of age, factoring in radiographic and clinical stability over the preceding decade, and describe strategies such as tapering dosing frequency or switching to lower-efficacy agents rather than abrupt discontinuation.
The conversation closes with an update on family planning in MS, where new data presented at CMSC reinforce the safety of anti-CD20 therapies during pregnancy and breastfeeding. Montgomery and Marini review a 10-year dataset of about 5000 pregnancies on ocrelizumab (Ocrevus; Genentech), a large safety analysis of ofatumumab (Kesimpta; Novartis Pharmaceuticals) showing no increase in birth malformations, and early transfer-into-breastmilk data on ublituximab (Briumvi; TG Therapeutics). They also touch on the limited but growing evidence for GLP-1 receptor agonists in patients with MS, noting no known drug interactions with DMTs and possible indirect benefit through weight-related disease modulation, though neither pharmacist currently prescribes GLP-1s for an MS indication.
