Practical Guidance on the Use of Cladribine Tablets in the Management or Relapsing Multiple Sclerosis: Expert Opinion from Qatar

Figures & data

Box 1 Multiple Sclerosis in Qatar

Prevalence:	93 (95% CI: 83 to 105)/100,000 population (medium-to-high prevalence) Female: male ratio 1.73:1
Clinical features:	Relatively low median EDSS score (=2) at presentation Preponderance towards sensory (65%) and visual (45%) symptoms, vs less common presentation with motor (43%), cerebellar (32%), brain stem (27%), bladder or bowel (10%), or spinal cord (14%) symptoms Relatively mild disability (see above) but more severe radiologic presentation vs neighbouring countries

Notes: Abstracted from data presented in references 8 and 9.

Abbreviation: EDSS, Kurtzke Expanded Disability Status Scale.

Figure 1 Consensus ratings of the efficacy and safety of disease-modifying therapies (DMTs) used in the management of relapsing multiple sclerosis. Expert neurologists (the authors) rated safety and efficacy on a Likert scale of 1 (least favourable) to 7 (most favourable). Average ratings are shown here.

Table 1 Summary of Recommendations

Newly-diagnosed MS	This is a heterogeneous group of patients: consider carefully individual histories, MS disease activity and prognostic factors for poor long-term MS outcomes 75–90% of patients with active MS^a are likely to be suitable for initial management with cladribine tablets. All patients with highly active MS^a are likely to be suitable for initial management with cladribine tablets. The remaining 10–25% of patients with low-risk, mild MS presentations are suitable for the escalation approach starting with a first-line DMT.
Switchers from 1st-line DMTs	Consider cladribine tablets for patients switching from a 1st-line DMT
Switchers from high-efficacy DMTs	No consensus: consider individual patient circumstances and preferences.
Years 3 and 4 of cladribine tablets	No need for re-treatment in the absence of MS disease activity (continue to monitor as usual) Retreat with 2 courses of cladribine tablets in the event of moderate MS disease activity^b Retreat with 2 courses of cladribine tablets or switch to an alternative high-efficacy DMT in the event of significant MS disease activity^c
Beyond year 4 of cladribine tablets	No need for re-treatment in the absence of MS disease activity (continue to monitor at longer intervals) Retreat with 2 courses of cladribine tablets in the event of moderate MS disease activity^b Retreat with 2 courses of cladribine tablets or switch to an alternative high-efficacy DMT in the event of significant MS disease activity^c

Notes: ^aSee text for definitions. ^b≤3 MRI lesions with or without a clinical relapse. ^c>1 relapse, a disabling relapse, or a high number of T2 MRI lesions. Based on expert opinion.

Abbreviations: DMT, disease modifying therapy; MS, relapsing multiple sclerosis.

Table 2 Factors Influencing the Suitability of Cladribine Tablets for Different Subgroups of Patients with Relapsing MS

Attribute	Average Level of Agreement: 1 = No Support for Use of Cladribine Tablets, 7 = Strong Support for Use of Cladribine Tablets
Use of cladribine tablets in specific patient subgroups:  DMT-naïve patients  Patients switching from 1st-line DMTs  Patients switching from other high-efficacy DMTs	6 7 4.5
Attributes of cladribine tablets:  Reduces relapse rates  Reduces MRI activity  Good tolerability  Good long-term safety	6.5 6 7 5.5

Note: Based on expert opinion.

Abbreviation: DMT, disease modifying therapy.