Improving the Management of Multiple Sclerosis

This edition of The Neurology Report focuses on providing and improving the continuum of care given to patients with multiple sclerosis, from recent advances in our understanding of its immunologic underpinnings to the latest developments in diagnosis and treatment, ending with a frank discussion of important controversies facing practitioners today.

VIEW Report
George H. Kraft, MD, MS
 George H. Kraft, MD, MS

Multiple sclerosis (MS) is an immune-mediated disease characterized by inflammatory and degenerative processes in the brain and spinal cord. Over the past 21 years, the introduction of 10 different disease-modifying therapies (DMTs), combined with advances in symptomatic management and rehabilitation, has made it possible to slow the progression of MS and improve patients' quality of life. The number of new DMTs currently in the pipeline reflects the vast amount of ongoing research into the immunopathology of MS and the underlying factors that lead to neuronal deterioration and disability.

The joint 28th Annual Meeting of the Consortium of Multiple Sclerosis Centers (CMSC) and the 19th Annual Meeting of the Americas Committee for Treatment and Research in Multiple Sclerosis (ACTRIMS), was held May 28–31, 2014, in Dallas, Texas. This joint meeting represented one of North America's largest and most comprehensive gatherings of clinicians, nurses, and researchers to discuss all facets of MS and its effects on every aspect of patients' lives and to share research findings. This edition of The Neurology Report represents a distillation of some of the more significant observations revealed at that meeting, the challenges that lie ahead, and a glimpse of what the future holds for both patients with MS and the team of professionals who care for them.

UNDERSTANDING THE IMMUNOLOGY OF MS
Any discussion about the immunologic underpinnings of MS must start with an appreciation of the normal immune response. Kathleen Costello, MS, ANP-BC, MSCN, and Anne Gocke, PhD, from the National Multiple Sclerosis Society, the Johns Hopkins Multiple Sclerosis Center, and the Johns Hopkins University School of Medicine in Baltimore, describe the normal immune response and how it changes in patients with MS, the variety of cells involved in protecting the body from foreign invasion and the molecules they produce to help them in this task, the etiology of neurologic inflammation in MS, recent insights into the inflammatory and degenerative mechanisms underlying relapsing and progressive forms of MS, and the mechanisms of action of DMTs currently being marketed or developed.

ASSESSING VISUAL CHANGES IN MS
Patients with MS often experience visual dysfunction along with other physical impairments. Salim Chahin, MD, MSCE, from the University of Pennsylvania Perelman School of Medicine in Philadelphia, describes in detail common visual effects (eg, optic neuritis, diplopia, and nystagmus) related to the disease, their signs and symptoms, the diagnostic procedures used to identify them and assess the degree of impairment, and effective strategies for assessing the severity of deterioration in visual acuity. Dr. Chahin also offers evidence that visual outcome measures may indicate the severity of MS and the degree of dysfunction it causes in individual patients. Finally, he presents evidence that studying visual function can lead to a better understanding of fatigue in MS patients.

INFECTIOUS COMPLICATIONS OF MS THERAPIES
Carrie M. Hersh, DO, from the Mellen Center for Multiple Sclerosis Treatment and Research at the Cleveland Clinic, provides a comprehensive review of opportunistic infections associated with the use of certain DMTs in the treatment of relapsing MS. In many cases, these infections, including fungal and herpesvirus infections, may have taken hold of the immune system years earlier, and the immunologic compromise caused by DMTs may allow proliferation of the infectious agent(s), resulting in clinical disease. In addition, DMTs may increase the risk of autoimmune conditions and alter the immunologic response to vaccinations. Dr. Hersh points out the dangers of progressive multifocal leukoencephalopathy (PML) related to the use of natalizumab, the latest consensus on diagnosing PML, best practices in treating it, and the risk of precipitating immune reconstitution inflammatory syndrome (IRIS) upon suddenly withdrawing natalizumab in patients who develop PML.

INFORMING DECISIONS TO IMPROVE THE CONTINUUM OF CARE
Mirla Avila, MD, from Texas Tech University Health Sciences Center in Lubbock, continues this discussion with an article on risk factors for MS development and progression, current therapeutic regimens, and factors that may impede the benefits of therapy from being realized. In addition, Dr. Avila provides scenarios of relapsing-remitting MS (RRMS) that may herald the need for a change in therapy and offers strategies for improving patient compliance. During this session, speakers presented two case studies that represented typical clinical scenarios—one involved the initial diagnosis and treatment of a woman suspected of having MS, and the other involved the need to change treatment for a woman who had been receiving therapy for the disease and who exhibited new radiologic lesions on brain magnetic resonance imaging.

CONTROVERSIES IN THE TREATMENT OF MS
Neurologists and other healthcare professionals have many divergent opinions on the optimal management of MS. During an interactive session, Sara S. Qureshi, MD, from The University of Texas Southwestern Medical School in Dallas, recounts discussions concerning important controversies facing practitioners who treat MS patients. Among the subjects covered are whether parenteral or oral drugs should be used as first-line DMTs in patients with RRMS; whether DMTs should be continued in patients who have advanced to secondary-progressive MS (SPMS); and whether the toxicity of alemtuzumab, if it is ever approved in the United States for the treatment of MS, will limit its use to induction therapy or second-line therapy in patients with refractory disease.

In summary, this edition of The Neurology Report provides both a basic understanding of the disease processes underlying the neuroimmunology of MS and novel perspectives on the management of this disease that have generated considerable controversy. We are grateful to our authors for providing these illuminating reviews of a variety of subjects so pertinent to modern clinical practice of managing our patients with MS. Certainly, we are on the cusp of important breakthroughs in the management of this often-challenging disease, as we gain more understanding of its immunopathology as well as knowledge of the mechanisms of action and the risks and benefits of the many DMTs now available and those under development. Ensuing issues of The Neurology Report will follow these advances and continue to explain them in a way that will foster better treatment of this complex and important disease.

Dr. Kraft is former director of the Western Multiple Sclerosis Center, Principal Investigator of the Multiple Sclerosis Research and Training Center, and Alvord Professor of Multiple Sclerosis Research at the University of Washington School of Medicine in Seattle, where he is currently Affiliate, Institute of Stem Cell and Regenerative Medicine, Medical Director of the Multiple Sclerosis Project ECHO (Extension for Community Health Care Options), and Emeritus Professor of Rehabilitation Medicine and Neurology.



This activity is supported by an educational grant from Biogen Idec.