Daniel Ontaneda, MD

“Although MRI has been a very useful tool, and a very sensitive tool for the diagnosis of MS, perhaps there is some room to increase the specificity of the diagnostic criteria.”

Earlier this month, the National Institutes of Health (NIH) awarded a $7.2 million grant to Cleveland Clinic for a prospective research study, referred to as CAVS-MS, to uncover more about central vein sign (CVS), and whether it can serve as a reliable biomarker for multiple sclerosis (MS).

The prospective study, referred to as CAVS-MS, will enroll 400 patients with typical or atypical presentations of MS at 11 participating centers in North America, with Cleveland Clinic serving as the coordinating center. The study is being conducted under the auspices of the North American Imaging in MS Cooperative. The co-principal investigator of the study and neurologist at Cleveland Clinic’s Mellen Center for Multiple Sclerosis, Daniel Ontaneda, MD, PhD, believes that up to 20% of MS diagnoses turn out to be inaccurate. If it shows efficacy, CVS may be able to improve diagnostic accuracy and simplify clinical decision-making.

, Ontaneda detailed the many reasons why misdiagnosis rates are so high in MS, and placed emphasis on diagnosing and treating patients as early as possible.

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The neurologist at Cleveland Clinic’s Mellen Center for Multiple Sclerosis and co-principal investigator of the CAVS-MS study discusses the reasons for the high rates of misdiagnosed MS.

Daniel Ontaneda, MD, PhD: How Multiple Sclerosis Can Be Misdiagnosed 

“You have to make an individualized decision and it has to be based on the mechanism of action of the medication you’re coming off of, how quickly you think that medication is going to stop acting, and how active the patient’s disease activity was to start with.”

When presenting data on the real-world use of the relapsing or primary progressive forms of multiple sclerosis (MS) treatment ocrelizumab (Ocrevus, Genentech), Daniel Ontaneda, MD, and his colleagues were often asked about the wash-out periods their patients undertook when switching from their original therapy.

As such, the staff neurologist at Cleveland Clinic's Mellen Center spoke about his best practices in providing patients the proper amount of washout time when switching from one disease-modifying therapy to another. Ultimately, there is variability, and he noted that it has to be an individualized method for each patient, with the goal of minimizing the washout period, as that time frame is the time in which they are at the highest risk for a potential relapse.

To find out more about his best practices and any advice he had for his peers who might be switching a patient’s MS therapy, 

 spoke with Ontaneda in an interview on the floor of the Americas Committee for Treatment and Research in MS (ACTRIMS) in Dallas, Texas.

The staff neurologist at Cleveland Clinic's Mellen Center spoke about his clinical experience in switching patients from their current disease-modifying therapy to ocrelizumab.

Daniel Ontaneda, MD: Switching Therapies for Patients With MS

“Once a medication is approved by the regulatory agencies and enters into clinical practice, we start using it. That’s where effectiveness [versus efficacy] comes into play. That’s not how something works in a clinical trial compared to something else, it’s how well it works in a real-world scenario.”

When ocrelizumab (Ocrevus, Genentech) was granted FDA approval in May 2017, multiple sclerosis (MS) got its first treatment for the primary-progressive form of the disease. And while it showed impressive efficacy in the clinical trials, there was some hesitation as to whether or not this would be replicable in the real world.

To determine this, a group of physicians at the Cleveland Clinic’s Mellen Center for MS, including Daniel Ontaneda, MD, undertook a study to observe the real-world effectiveness of ocrelizumab. The center similarly conducted these observational studies with other recently approved treatments such as fingolimod (Gilenya, Novartis).

At the Americas Committee for Treatment and Research in MS (ACTRIMS) Forum in Dallas, Texas, the staff neurologist at the Mellen Center shared his real-world experience with the treatment in primary-progressive MS patients. He detailed the importance of these observations in determining the effectiveness of a treatment in patients in clinical practice, as opposed to knowing the efficacy of a treatment—which is entirely measured in clinical trials in comparison to placebo or another treatment.

To find out more about the group’s work, 

 spoke with the staff neurologist at Cleveland Clinic's Mellen Center in an interview.

The staff neurologist at Cleveland Clinic's Mellen Center spoke about the real-world observational study of the primary-progressive MS treatment.

Daniel Ontaneda, MD: Real-World Observations With Ocrelizumab

“We think it has the potential to really help us with the question of misdiagnosis and to just simplify the diagnosis [of MS] overall.”

Unfortunately, a challenge in multiple sclerosis (MS) treatment that still persists is misdiagnosis. One of the reasons for this is the presence of lesions in the brain—a trademark of the disease&mdash;can occur even in patients who do not have MS. Although, there is work being done to help address this problem, which can impact physicians across the country.

Research has shown that the majority of lesions present in patients with MS have a small but detectable vein running through their center. This vein can be imaged successfully with a recently developed technique involving magnetic resonance imaging. Now, researchers are seeking to validate this central vein sign, which has shown to be both quick and affordable, as a means of differentiating patients with MS from those without.

Daniel Ontaneda, MD, is one of the staff neurologists at the Mellen Center for MS at Cleveland Clinic working on this technology. He noted that a prospective study of the central vein sign is still needed. But, a trial is actually ongoing, and he shared the details of the initial pilot study with 

 in an interview at the Americas Committee for Treatment and Research in Multiple Sclerosis (ACTRIMS) 2019 Forum in Dallas, Texas. 

The staff neurologist at the Mellen Center for MS at Cleveland Clinic spoke about the potential for the central vein sign to help address issues of misdiagnosis in multiple sclerosis

Author | Daniel Ontaneda, MD

Articles

Daniel Ontaneda, MD, PhD: How Multiple Sclerosis Can Be Misdiagnosed

Daniel Ontaneda, MD: Switching Therapies for Patients With MS

Daniel Ontaneda, MD: Real-World Observations With Ocrelizumab

Daniel Ontaneda, MD: Diagnosing MS With the Central Vein Sign