b'Medicine & Researchwere published in Multiple Sclerosis Journalmay better control MS and reduce healthcareExperimental, Translational and Clinical.use. The study was published in Therapeutic Thrower- People living with MS sometimesAdvances in Neurological Disorders. reportaworseningofsymptomsastheyThrower- Weve certainly come a long way come due for their next dose of certain DMTs.since the days when we could only offer the This phenomenon has been termed the crapABC drugs (Avoenx, Betaseron, or Copaxone) gap and was rst widely reported in thoseas options for those living with MS. If one using Tysabri (natalizumab). We now hearincludes generic and biosimilar formulations, similar complaints from some using infusionswe now have nearly 30 options. As more of rituximab, Ocrevus (ocrelizumab), andoptions have become available, our options Briumvi(ublituximab).Thiswearing-offare becoming more effective. Natalizumab effect has also been reported with monthly(Tysabri) is one of our more effective therapies injections of Kesimpta (ofatumumab). for relapsing forms of MS. Should we start a Researchers now have tried to measurehighly effective therapy such as natalizumab any objective worsening of walking for thoseas our rst-line or wait to see if something reporting a crap gap between Ocrevus doses.less effective works rst? I would argue that The good news is that no decrease in dailymost MS healthcare providers believe starting stepcount wasseenforthosereportingaa highly effective therapy as the first-line worsening of symptoms. This does not meantherapy offers the best chance for preventing that people dont feel worse; it only means thefuture disability. One of the barriers to this number of steps they took each day did notapproach can be health insurance companies worsen the symptoms. Other areas for futureand a policy called step edits. Imagine you research might focus on quality of life, fatigue,and your MS healthcare team decide your or cognitive dysfunction for people reportingrst-line therapy should be drug C. Drug C is the crap gap.ahighlyeffectivetherapy.Yourinsurance Findings suggest an early start tocompany has a policy that says you have to rst-line DMTs may better control MS try and fail drug A and B (moderately effective This retrospective observational study,therapies) before you can use drug C. Thats a conducted by researchers at Biogen andstep edit. There are many problems with step Cytel using U.S. insurance claims data fromedits, one of the biggest being that by the seven years, analyzed 1,568 adults newlytime the person with MS has failed drugs A diagnosed with MS who started treatmentand B, they may have accumulated a new permanent level of disability.with natalizumab. Of these, 1,174 received itThis study speaks in a language that as a rst treatment (rst-line) and 394 afterhealthcare insurance companies understand, trying other drugs (later-line). The study foundthat being utilization. This study showed that rst-line use led to a larger reduction inthat those with MS who started natalizumab relapse rates (81 percent vs. 55 percent) andas their rst-line therapy not only had fewer greater decreases in hospital stays and outpatientrelapsesbutalsohadlowerhealthcare visits.Patientsstartingnatalizumabearlyutilization (less money spent by the insurance also stayed on treatment longer. The ndingscarrier) than those who started the highly suggestthatbeginningnatalizumabearlyeffective therapy later.msfocusmagazine.org 40'