Weighing the Benefits and Risks of Stopping DMT After 60
The decision to continue or discontinue disease-modifying therapy (DMT) is a complex and personal one for people with multiple sclerosis (MS). For older adults, specifically those over the age of 60, this decision comes with unique considerations. As a person ages, the immune system naturally becomes less active, a process known as immunosenescence. This can lead to a decrease in the inflammatory attacks that characterize relapsing forms of MS, making the benefits of aggressive immune-suppressing therapies less clear. However, the risk of disease progression, even without visible relapses, can still remain.
The Evolving Evidence on DMT Discontinuation
Clinical trials and observational studies are providing valuable data to help guide these decisions. The multicenter DISCOMS trial, published in Lancet Neurology in 2023, was a landmark study on DMT discontinuation in patients aged 55 and older. While the study could not definitively conclude that stopping was non-inferior to continuing, it found that patients who stopped had only a slightly higher risk of new MRI activity over two years compared to those who continued. Significantly, there was no difference in disability worsening between the groups. This study provides concrete data that informs the conversation between patients and their healthcare providers. It is important to note that most participants were on older, injectable DMTs, and the findings may not apply to newer, more potent therapies.
Other research, such as a 2018 observational study from the Cleveland Clinic, also supported the idea that stopping DMT after age 60 could be a safe strategy for some patients [2]. That study analyzed a cohort of 600 MS patients over 60 and found minimal effect on quality-of-life outcomes and MRI indicators for those who discontinued therapy [2]. A separate 2021 study from the University at Buffalo, however, provided a contrasting viewpoint, showing that even in a group of previously stable MS patients of varying ages who discontinued medication, about a third experienced disability progression afterward [3]. These findings suggest that the risk of progression, even without clinical relapses, remains a concern.
Factors to Consider with Your Neurologist
Stopping DMT is not a one-size-fits-all approach. The conversation with your neurologist should be highly personalized and cover several critical factors. A long history of stable disease, defined by no relapses and no new MRI activity for several years, is a key prerequisite. The type of DMT is also vital, as some medications, like fingolimod or natalizumab, carry a significant risk of 'rebound' disease activity if stopped abruptly. The potential risks of continuing therapy, such as an increased risk of infection or other side effects in an aging body, must also be weighed against the potential benefits. The decision process should be a shared one, where both you and your doctor evaluate all the pros and cons based on your unique health profile.
Potential Risks and How to Mitigate Them
While studies suggest that for carefully selected individuals the risks may be manageable, they are not zero. The primary risks include the potential for renewed inflammatory disease activity, such as a relapse or new lesions on an MRI, and the potential for disability progression. For certain high-risk DMTs, the rebound effect can be particularly severe. Therefore, a structured plan for monitoring is essential if discontinuation is pursued. This might involve:
- Regular clinical evaluations with a neurologist.
- Routine MRI scans to monitor for new or enlarging brain lesions.
- Discussion of other health issues, such as comorbidities, that might influence MS progression.
- Having a plan in place for if disease activity returns.
Comparison of Continuing vs. Discontinuing DMT After 60
| Factor | Continuing DMT | Discontinuing DMT |
|---|---|---|
| Disease Activity | Lower risk of new relapses and MRI activity. | Small, but measurable, risk of new activity, even if stable for years. |
| Side Effects | Ongoing risk of side effects, which may increase with age. | Eliminates or reduces DMT-related side effects. |
| Treatment Burden | Requires continued adherence to treatment schedule. | Frees patient from medication regimen and associated appointments. |
| Monitoring | Routine follow-ups and MRI scans are standard. | Increased need for close monitoring to catch any renewed activity early. |
| Cost | Ongoing financial burden from medication and related costs. | Reduces or eliminates financial costs of therapy. |
| Medication Specifics | Risk/benefit depends on the specific drug used. | Risk of 'rebound' activity is high with some drugs (e.g., natalizumab, fingolimod). |
The Importance of Long-Term Monitoring
If you and your healthcare team decide to stop DMT, vigilance remains crucial. The absence of relapses does not always mean the disease has stopped progressing, especially in older age where gradual, non-inflammatory progression can occur. Staying in close contact with your neurologist and continuing regular MRI monitoring can help catch any signs of renewed disease activity early, allowing for a timely decision to resume therapy if necessary. This underscores the need for a long-term plan, not just an immediate discontinuation. For further information and resources on managing MS, you can visit the National Multiple Sclerosis Society.
Conclusion: An Individualized Approach
Ultimately, whether it is safe to stop MS disease modifying therapy after age 60 depends on the individual. The process is a careful balancing act between the reduced inflammatory activity often seen with age and the persistent, low-grade risk of silent disease progression. Thanks to trials like DISCOMS and the growing body of evidence, older patients with stable MS can have an informed conversation with their neurologist about the possibility of discontinuing or de-escalating therapy. It is a decision that requires a thorough review of medical history, disease stability, medication type, and a robust monitoring plan to ensure the best possible long-term outcome.
