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• Early treatment start versus late treatment start should have been defined more accurately
  Ahmad Asadipouya
  Published on: 14 March 2023

• Published on: 14 March 2023

  Early treatment start versus late treatment start should have been defined more accurately

  • Ahmad Asadipouya, Student Research Committee Shiraz University of Medical Sciences

  To the Editor
  I have read the work conducted by Dr. He et al. on importance of early treatment of patients with multiple sclerosis and its association with outcomes reported by the patients (1). The work entitled “Association between early treatment of multiple sclerosis and patient-reported outcomes: a nationwide observational cohort study” was first published in Journal of Neurology, Neurosurgery and Psychiatry in 7th of December, 2022. This observational study showed that earlier initiation of treatment with disease-modifying treatment in the patients with multiple sclerosis was statistically significantly associated with patient-reported physical symptoms. There are some points that I thought were uncertain and unclear in the study.
  The study used a cutoff of two years to divide the participants into two groups of early treated patients who were those whose treatment was initiated within two years from the onset of the disease and late treated patients with treatment initiation between two and four years after onset. The authors justified that this classification was based on the guideline recommended by international committees advocating the initiation of disease modifying treatment in less than 12 months; however, it is not clear how this recommendation support the cutoff used in the study. In previous similar studies, a cutoff value of 6 months was mainly considered (2-4). Furthermore, it would have been better if the authors also had reported the time...

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  To the Editor
  I have read the work conducted by Dr. He et al. on importance of early treatment of patients with multiple sclerosis and its association with outcomes reported by the patients (1). The work entitled “Association between early treatment of multiple sclerosis and patient-reported outcomes: a nationwide observational cohort study” was first published in Journal of Neurology, Neurosurgery and Psychiatry in 7th of December, 2022. This observational study showed that earlier initiation of treatment with disease-modifying treatment in the patients with multiple sclerosis was statistically significantly associated with patient-reported physical symptoms. There are some points that I thought were uncertain and unclear in the study.
  The study used a cutoff of two years to divide the participants into two groups of early treated patients who were those whose treatment was initiated within two years from the onset of the disease and late treated patients with treatment initiation between two and four years after onset. The authors justified that this classification was based on the guideline recommended by international committees advocating the initiation of disease modifying treatment in less than 12 months; however, it is not clear how this recommendation support the cutoff used in the study. In previous similar studies, a cutoff value of 6 months was mainly considered (2-4). Furthermore, it would have been better if the authors also had reported the time between symptoms onset to the diagnosis and the time between the diagnosis to the treatment initiation with disease modifying agents for to have a more holistic picture.
  Second, the study aimed to compare the patient-reported outcomes between two groups of the patients with multiple sclerosis, those with early treatment and those with late treatment; however, they did not consider the issue that different factors were already identified in the literature to be associated with symptoms and outcomes reported by patients and these factors should also be should be added into the statistical analyses when measuring the association of the timing of treatment and the outcomes. In a study conducted by Farran et al. on patients with multiple sclerosis in Lebanon and the Middle East and North Africa region, it was shown that age of these individuals, their gender and some sociodemographic and clinical variables could be associated with their perceived symptom and health-related quality of life (5). In this study it was mentioned in Table 1 that there were significant differences in the age and gender of the two groups of the study which could endanger the credibility of the findings in the study. Besides, the participants of these two groups had even significantly different baseline number of relapses and pretreatment Expanded Disability Status Scale; therefore, the disease status and severity might be different in these two groups, a potential source for another bias.
  Authors’ contributions: Both authors contributed in all processes of the preparation of this paper.
  Acknowledgement: None.
  Conflict of Interest statement: I declare no conflict of interests.
  Funding: None.
  References
  1. He A, Spelman T, Manouchehrinia A, Ciccarelli O, Hillert J, McKay K. Association between early treatment of multiple sclerosis and patient-reported outcomes: a nationwide observational cohort study. Journal of Neurology, Neurosurgery & Psychiatry. 2022:jnnp-2022-330169.
  2. Karampampa K, Gyllensten H, Murley C, Alexanderson K, Kavaliunas A, Olsson T, et al. Early vs. late treatment initiation in multiple sclerosis and its impact on cost of illness: A register-based prospective cohort study in Sweden. Multiple sclerosis journal - experimental, translational and clinical. 2022;8(2):20552173221092411.
  3. Kavaliunas A, Manouchehrinia A, Stawiarz L, Ramanujam R, Agholme J, Hedström AK, et al. Importance of early treatment initiation in the clinical course of multiple sclerosis. Multiple sclerosis (Houndmills, Basingstoke, England). 2017;23(9):1233-40.
  4. Landfeldt E, Castelo-Branco A, Svedbom A, Löfroth E, Kavaliunas A, Hillert J. The long-term impact of early treatment of multiple sclerosis on the risk of disability pension. Journal of neurology. 2018;265(3):701-7.
  5. Farran N, Safieddine BR, Bayram M, Abi Hanna T, Massouh J, AlKhawaja M, et al. Factors affecting MS patients’ health-related quality of life and measurement challenges in Lebanon and the MENA region. 2020;6(1):2055217319848467.

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  Conflict of Interest:
  None declared.

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