When and how can you stop taking a disease-modifying treatment (DMT)?
At what age do the risks of taking a DMT outweigh the benefits?
I am often asked for guidance on how to address this question.
As people age, their immune system becomes less and less effective at creating inflammation. There are fewer and fewer autoimmune flares of disease activity, meaning fewer relapses and fewer new, enhancing lesions but more infections and cancers that the immune system cannot overcome, leading to serious health decline. So when does continuing immune-suppressing DMTs outweigh the higher risk of infection and/or cancer? Neurologists and other specialists and their patients want guidance on how to address this question.
This paper (PMID: 37740822) reviewed and analyzed the published papers addressing this question. They found 22 papers with a pooled sample of 2,942 patients who were followed for 1-7 years after stopping DMTs. The pooled rate for relapse and disability progression were 6.7 and 5.8 per 100 patient years respectively. Patients who were older (β = -0.65, p = 0.006), who took the DMTs longer (β = -2.22, p = 0.001), and those with a longer period of disease stability (β = -2.74, p = 0.002) showed a lower risk of relapse events. Using meta-regression equations, the risk of relapse events after DMT discontinuation became negligible after 60 years of age, and after either 10 years of DMT exposure or 8 years of disease stability. Unfortunately none of the studies examined the impact of addressing and improving modifiable risk factors.
When I teach other health practitioners about treating multiple sclerosis and neuroimmune disorders, I review this dilemma and the limited body of research that guides how DMTs can be safely discontinued. I also explain my approach in clinical practice, which is to tell patients we do not have sufficient research that addresses this question.
I do not want people to abruptly stop their DMTs for multiple sclerosis or any systemic autoimmune condition. I want people to have a minimum of 1-3 years of no disease activity that is detectable by symptoms or imaging or blood work (according to the standards of their specific disease). Only then will I begin a process of gradual transition to a DMT that has fewer side effects and may be less potent (for example, Copaxone). Then we can have a discussion over whether that is continued or gradually tapered. The older the person is, the longer the person has been on DMTs, and their level of current functioning are factors to consider, as is their risk tolerance for disability progression, infection, and cancer. It’s also important to discuss the commitment to consistent, permanent implementation of a therapeutic lifestyle without intermittent slip ups, which may support better outcomes.
We see many people successfully transition off of their DMTs, and also have some patients who prefer to stay on Copaxone. Whatever you decide about DMTs, I want you to work on addressing modifiable lifestyle factors to create the best environment for your cells. Work with your primary care physician or a trained and certified Wahls Practitioner to help you implement these changes. Or take our online course, Autoimmune Intervention Mastery Course, which helps people more successfully improve modifiable lifestyle factors, including diet, stress management, exercise, smoking and other toxin exposures. We have even tested how well this course does in a clinical trial. In a waitlist control study, those who took the course saw a significant reduction in their fatigue compared to the control group who waited 12 weeks before they got access to the course.
Work on improving your modifiable lifestyle factors, which can help restore your health and vitality by providing the best environment for your cells, regardless of what you decide about taking DMTs.
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