3. Diskusjon
4.8 Konklusjon
Det er til nå publisert et ganske stort antall kliniske fase II-studier om HSCT-behandling ved MS. Da heterogeniteten blant studiene er stor og kvaliteten og størrelsen på studiene til dels er lav, er resultatene for effekt og sikkerhet av HSCT ikke pålitelige nok. En stor andel av de vurderte studiene viser imidlertid resultater som, hvis man kan stole på disse, må ansees som svært gode dersom disse sammenlignes med effekten av dagens tilgjengelige medikamentelle behandling. HSCT er en omfattende behandling med en ikke ubetydelig komplikasjons- og mortalitetsrisiko, samt at en rekke bivirkninger er svært hyppige under den initiale fasen av behandlingen. Da det imidlertid sees en synkende mortalitet, spesielt ved bruk av
kondisjoneringsregimer med lav intensitet, bør HSCT likevel ansees som et mulig fremtidig behandlingsalternativ for MS-pasienter med alvorlig sykdom og manglende effekt av tilgjengelig godkjent behandling. For å etablere sikker evidens for effektivitet og bivirkningsprofil må randomiserte kontrollerte studier der HSCT sammenlignes med godkjente sykdomsmodulerende medikamenter gjennomføres. Utfallsmål benyttet i eksisterende studier varierer, og en standardisering bør etterstrebes for å muliggjøre
sammenligning av studiene og sammenligning av resultater med medikamentell behandling.
Pasienter som er i et inflammasjonspreget stadium av sykdommen ser ut til å ha best effekt av behandlingen, mens pasienter i progressiv fase med kroniske forandringer ser ut til å ha dårligere effekt. Det vil være viktig å gjennomføre analyser som kan gi en bedre forståelse av mekanismene ved HSCT og hva det er som gjør at noen pasienter responderer bedre på behandlingen enn andre. Ved valg av kondisjoneringsregime må grad av immunablasjon og tilgjengelige bevis på effekt veies opp mot komplikasjons- og mortalitetsrisiko. Gjennomførte
studier indikerer at regimer med høyere intensitet gir høyere toksisitet og økt
mortalitetsrisiko, og lav- og mellomintensitetsregimer kan derfor synes som det mest
forsvarlige valget på nåværende tidspunkt. Med en nåværende mortalitetsrate estimert til ca.
1 %, og en rekke studier der denne har ligget på 0 %, kan det kanskje argumenteres for at flere bør få tilbud om behandlingen. At det i Norge nå er blitt bevilget penger til en
randomisert kontrollert studie, vil bidra til at flere pasienter her til lands kan behandles med HSCT innenfor rammen av en slik studie og at man kan komme nærmere en konklusjon vedrørende effekten av HSCT ved MS.
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