Board-certified neurologist and multiple sclerosis specialist; founder and CEO, Joi Life Wellness Group Multiple Sclerosis Center

Mitzi Joi Williams, MD

in the field of multiple sclerosis (MS). As treatment options continue to expand—now with over 20 therapies, including options for primary and secondary progressive disease—the science in the field is focusing more on other issues such as understanding and tracking disease progression, approaches to treatment initiation, and the roles of diet and exercise in pathogenesis and disease course. This issue of 

There is an increasing volume of data characterizing the more severe disability seen in Black populations, but the roles of social determinants of health and underlying biology remain unclear. Our cover story, “

Disproportionate Neurodegeneration in Black Patients With MS: The Need for Stratified Treatments

” by Darin T. Okuda, MD, FAAN, FANA, examines evidence in the literature regarding both phenotype of MS in Black patients and imaging markers of early neurodegeneration. This piece highlights the importance of individualized treatment approaches but also raises important questions regarding how we approach therapeutic decision-making in populations that are known to have more aggressive disease. This extremely important topic emphasizes the dire need for increased diversity in clinical research to make results more generalizable and better understand disparate outcomes.

It has been well known that exercise provides cardiovascular benefit for patients living with MS, but the prescription of exercise training to help with specific symptoms of MS including fatigue and cognitive dysfunction is less well known. In the feature story “Exercise Training in Multiple Sclerosis” by Robert W. Motl, PhD, he discusses the role of exercise training in MS and our current understanding of its benefits. Motl also provides interesting perspective and a review of studies focused on exercise training as a disease-modifying intervention for MS, as well.

As treatments become more effective, it has become more imperative to track effectiveness, but also disease progression. Torge Rempe, MD, and Tirisham Gyang, MD, provide an overview of available and emerging biomarkers in MS in their feature article. This piece first describes the role of biomarkers and qualities of good biomarkers. The authors discuss current well-known markers such as MRI, cerebrospinal fluid oligoclonal bands, and optical coherence tomography and how they can be used in both diagnosis and evaluating treatment response. The article also covers emerging biomarkers such as glial fibrillary acidic protein and neurofilament light chain and the potential utility of these markers once they become more widely available in clinical practice.

As the therapeutic landscape becomes more complex, it becomes even more imperative that we engage in shared decision-making with our patients and their care partners to create the best individualized treatment plan possible. This plan should include early intervention with disease-modifying therapy, although there is not sufficient evidence to fully support escalation therapy versus early high-efficacy therapy. As evidence unfolds focused on the effects of diet, the gut microbiome, exercise, and comorbidities, these issues will also become more integral in initial and ongoing treatment plans.

We have not yet attained the ability to practice precision medicine in MS, but the scientific community is moving us closer to this goal. As we set our sights on moving past preventing disability to examining clinically definite improvement and reaching no evidence of disease activity as a treatment goal for our patients, we need a comprehensive approach to treatment that focuses not only on disease-modifying  therapy but also modifiable risk factors and wellness. Improving health outcomes for all ethnic groups and better understanding MS characteristics in minority populations will also play a key role in improving health equity in these populations but will hopefully lead to discoveries that allow us to increase quality of care for all people living with MS.

Articles

The field of MS is shifting focus to issues such as understanding and tracking disease progression, approaches to treatment initiation, and the roles of diet and exercise in pathogenesis and disease course.

Moving Toward a More Personalized MS Treatment Journey

“I think the biggest issue is that because we have such low numbers in our clinical trials, we don't really understand the role of any underlying biologic or genetic factors that may be playing a role, versus social determinants of health—access to care, insurance, [or] discrimination and bias on the part of healthcare providers. We don't have really a good understanding of what roles, or what proportions, those 2 things are playing in the disparate outcomes.”

The initiation of the CHIMES trial (NCT04377555) in minority populations with multiple sclerosis (MS) will evaluate the efficacy of ocrelizumab (Ocrevus; Genentech). According to Mitzi Joi Williams, MD, board certified neurology and multiple sclerosis specialist, and founder and CEO, Joi Life Wellness Group Multiple Sclerosis Center, the therapy was chosen due to studies that suggest the B-cell pathway may be more active in African American and Black individuals, as well as data showing that immunoglobulin G levels in the spinal fluid may be higher.

2021 Annual Meeting of the Consortium of Multiple Sclerosis Centers (CMSC)

 on the measures being evaluated in the trial, which will also look into different biomarkers, including blood biomarkers, that have not been largely studied in African American/Black and Hispanic/Latino populations with MS. When asked about the higher prevalence of MS and resultant outcomes in these populations, Williams emphasized experts’ lack of understanding as to whether this is related to underlying genetic factors or if it is predominantly tied to social determinants of health.

Videos

The founder and CEO of Joi Wellness Group Multiple Sclerosis Center described motivations behind the evaluation of ocrelizumab (Ocrevus; Genentech) in minority populations with multiple sclerosis.

Evaluating Ocrelizumab in the CHIMES Trial: Mitzi Joi Williams, MD

“We were very intentional about the way that we developed the trial. The steering committee included researchers of diverse backgrounds, but in our planning of the protocol, we also included patients, we included advocacy organizations, and we included input from Accelerated Care Project [for Multiple Sclerosis], which is a patient driven research organization. We tried to be very inclusive in the way that we developed the design of the trial.”

In order to address and better understand the underrepresentation of minority populations in multiple sclerosis (MS) clinical trials, the CHIMES trial (NCT04377555) was developed, set to include approximately 150 self-identified Black or African American and Hispanic/Latino patients with relapsing MS who are receiving treatment with ocrelizumab (Ocrevus; Genentech). Mitzi Joi Williams, MD, board certified neurology and multiple sclerosis specialist, and founder and CEO, Joi Life Wellness Group Multiple Sclerosis Center, spoke with 

, October 25-28, where she gave a presentation on the initiation of the study.

Williams outlined the trial design, describing the development as “very intentional” and inclusive, with organizers consulting an independent patient panel to ensure materials were culturally appropriate, as well as understandable. Researchers from diverse backgrounds were included on the steering committee, and during protocol planning, patients and advocacy organizations were consulted, with input coming from the Accelerated Care Project for Multiple Sclerosis. Williams also noted the relaxation of inclusion criteria to allow for patients with comorbidities to participate, provided transportation, as well as stipends for participation and childcare. Thanks to efforts to emphasize and advertise the study, enrollment has been completed 2 months ahead of schedule, Williams said. 

Outlining the development of the CHIMES trial in multiple sclerosis, the founder and CEO of Joi Life Wellness Group Multiple Sclerosis Center spoke on tactics to get underrepresented populations involved. [WATCH TIME: 2 minutes]

Designing an MS Clinical Trial Focused on Minority Populations: Mitzi Joi Williams, MD

“We have to take a broader look at both the institutional barriers, as well as the patient barriers, such as cost and time, which lead to the decrease in enrollment and trials.”

While emerging data suggest the risk of developing and incidence of multiple sclerosis (MS) is highest for Black people in the US—specifically Black women—minority populations continue to be underrepresented in MS clinical trials. Following her presentation at the 

, October 25-28, Mitzi Joi Williams, MD, board certified neurologist and multiple sclerosis specialist, and founder and CEO, Joi Life Wellness Group Multiple Sclerosis Center, spoke with 

 about the genesis of the CHIMES trial (NCT04377555), which aims at understanding this underrepresentation in a controlled setting. 

Smaller numbers of minority patients in clinical trials may be due to mistrust and the “history of unfair experimentation,” Williams said, as well as institutional barriers to enrollment and trials. Comparably, a lack of diverse researchers may also contribute to this underrepresentation, as certain investigators may be better equipped to speak to certain populations. Inclusion criteria often discount those with comorbidities, and as diabetes and hypertension are more common in minority populations, this creates another barrier to inclusion. Williams stressed the need to examine these barriers from the patient perspective, in terms of cost and time, as well as on the broader, institutional level. 

The founder and CEO of Joi Life Wellness Group Multiple Sclerosis Center outlined the motivations behind the trial, as well as potential reasons for underrepresentation. [WATCH TIME: 2 minutes]

Developing the CHIMES Trial for Minority Patients With MS: Mitzi Joi Williams, MD

“In some cases, the younger patients are more willing to take risks than some of the older patients in terms of side effects with some of the treatments. When we think about our high-efficacy treatments, we think about more potentially serious side effects. There are many who are willing— because they're at the height of their careers or want to have a family in the future—to go with some of those treatments that are higher efficacy that may have more potential adverse effects because they do want to be aggressive with the disease.”

As the millennial generation—those born between 1980 and 1995—moves closer to middle age, the percentage of the multiple sclerosis (MS) patient population made up of these individuals is increasing. With them, they bring generational differences, which, when coupled with the massive advances the field has taken since the turn of the century, require the occasional shift in approach to patient communication.

Mitzi Joi Williams, MD, board-certified neurologist and multiple sclerosis specialist, and founder and CEO, Joi Life Wellness Group Multiple Sclerosis Center, sees a number of millennial patients in her clinical care routine. She shared her experience with 

 in an interview, pointing to the potential differences of this group with regard to making therapeutic choices and the potential adverse effects associated with them.

Williams offered up insight into the care of these patients and detailed how the advances in MS care over the last 2 decades have helped make the process of shared decision-making smoother for this group. She also spoke to the millennial knowledge base about the disease, and how sometimes offering less information at first can be more fruitful than providing all of it at once.