More MS news articles for February 2001

Drug treatment of multiple sclerosis

BMJ 2001;322:299 ( 3 February )

[This article is a response to a previous article about MS treatments and their cost-efficacy published in the BMJ BMJ 2000;321:490-494 ( 19 August 2000 )]

Clinical review was unsystematic


Polman and Uitdehaag present a clinical review of drug treatment of multiple sclerosis that is unsystematic and makes no attempt to take account of existing systematic reviews of the evidence.1 In consequence, it has several important deficiencies as an assessment of the drugs available to help patients with this serious disease.

Firstly, the authors say that "the amount of [magnetic resonance imaging] lesions in the early phase of the disease predicts future disability" but make no comment about the conclusion of a recent meta-analysis of nine longitudinal studies that [gadolinium enhanced magnetic resonance imaging] "is not a strong predictor of the development . . . of disability."2

Secondly, they dismiss the older immunosuppressive drugs, saying that they have limited efficacy and considerable toxicity. They make no reference, however, to a recent systematic review of the randomised evidence about these drugs that puts them in context.3

Thirdly, they include a short paragraph about the cost utility of interferon beta, with one single reference. A recent systematic review of relevant studies from across the world addressing this question found three looking at relapsing-remitting and two at secondary progressive disease. In each case the cost per quality adjusted life year was high, which raises the question of whether people with multiple sclerosis might derive more benefit from resources invested in services other than interferon beta.4

The assessment of health technologies requires an unbiased and systematic assessment of the totality of the available evidence. People with multiple sclerosis are not helped by incomplete reviewsneither are healthcare decision makers.

Ruairidh Milne, senior lecturer in public health medicine.

Andy Clegg, senior research fellow.
Jackie Bryant, research fellow.
Wessex Institute for Health Research and Development, Mailpoint 728, University of Southampton, Southampton SO16 7PX

Competing interests:

All the authors were authors of a recent rapid review of the effectiveness, costs, and utility of a range of disease modifying drugs in multiple sclerosis. They also work for the National Coordinating Centre for Health Technology Assessment, which manages the health technology assessment programme on behalf of the NHS.


1.  Polman CH, Uitdehaag BMJ. Drug treatment of multiple sclerosis. BMJ 2000; 321: 490-494[Full Text]. (19-26 August.)
2.  Kappos L, Moeri D, Radue EW, Schoetzau A, Schweikert K, Barkhof F, et al. Predictive value of gadolinium-enhanced magnetic resonance imaging for relapse rate and changes in disability or impairment in multiple sclerosis: a meta-analysis. Lancet 1999; 353: 964-969[Medline].
3.  Clegg A, Bryant J, Milne R. Disease-modifying drugs for multiple sclerosis: a rapid and systematic review. Health Technol Assess 2000; 4: 1-101.
4.  Bryant J, Clegg A, Milne R. Cost utility of drugs for multiple sclerosis. Systematic review places study in context. BMJ 2000; 320: 1474-1475[Full Text]. (27 May.)

Authors' reply


Milne et al argue that our clinical review of drug treatment of multiple sclerosis is unsystematic and of course it is. The BMJ invited us to write a reviewusing under 2000 words and no more than 30 referencesthat was accessible to informed general practitioners; it was explicitly stated that the methods were not expected to be systematic.

In addition to stating that our review was unsystematic Milne et al make three points. Their first one addresses magnetic resonance imaging, and it is obvious that they are confused by the characteristics of the different magnetic resonance variables. Some of the references given in our paper (especially 4, 5, and 25) address this aspect in detail. With regard to their second and third remarks we can conclude only that the messages from their papers do not challenge our statements that immunosuppressive drugs have not found widespread acceptance and that interferon beta has a high cost.

People with multiple sclerosis are not helped by letters to medical journals in which scientists refer only to their own papers without making relevant new points - neither are healthcare decision makers.

C H Polman, professor.
B M J Uitdehaag, neurologist.
Department of Neurology, Academic Hospital Vrije Universiteit, PO Box 7057,1007 MB, Amsterdam, Netherlands

Competing interests:

Both authors have received research grants and lecturing and consultancy fees from various pharmaceutical companies dealing with multiple sclerosis, including those that manufacture the various forms of interferon beta and glatiramer acetate.

Other related articles in BMJ:

Regular review: Drug treatment of multiple sclerosis.
C H Polman and B M J Uitdehaag
BMJ 2000 321: 490-494. [Full text]

© BMJ 2001