Current Series: Multiple Sclerosis: A Disease of an Immune System Gone Awry

Patricia K. Coyle, MD: In 2018, the American Academy of Neurology, AAN, issued an update on its Practice Guidelines for the treatment of multiple sclerosis [MS]. The diagnostic criteria, the McDonald diagnostic criteria, are strictly dealing with the diagnosis of MS. They say nothing about treatment. The AAN 2018 Practice Guidelines are focused on what we can say meaningfully about treating MS individuals, largely in relapsing forms, but also now in primary-progressive disease. These are a number of practice guidelines that reviewed the literature and came up with statements that involved initiating a disease-modifying therapy, how it should be administered, what you should take into consideration, and switching disease-modifying therapy. There are a number of statements that review the literature and have different strengths of confidence. Finally, there are even a few points on considering stopping a disease-modifying therapy. The AAN Practice Guidelines are focused strictly on therapy, not diagnosis.

Clyde E. Markowitz, MD: The goals of therapy for MS are to stop the disease from evolving in all metrics that we have. That’s the goal. That metric includes clinical attacks, new lesions on MRI [magnetic resonance imaging] scans, slowing the rate of disability, and dealing with a number of pieces that we don’t really have a great handle on, such as cognition, fatigue, and other symptomatology. That’s really the goal. The goal is an improved quality of life.

What we’ve been able to accomplish over the last couple of decades is introducing treatments that really alter the disease course. Whereas previously, all we had was the idea of treating a symptom that a patient may have. Now we can actually alter the course of their disease with the treatments we have available.

Fred D. Lublin, MD: We entered the therapeutic era of MS in 1993, 25 years ago, when interferon beta-1b was approved. In the ensuing 25 years, we have probably developed around 14 agents—it changes a little bit—which have given us a wider range of choices and a wider range of efficacies to choose from. The evolution has gone from 1-drug-fits-all to multiple drugs, multiple routes of administration, and multiple considerations around what you want the efficacy to be; safety and tolerability; comorbidities, or what else is going on medically with that individual that might affect the therapies; and, very importantly, the patient’s role and input in choosing the therapies. This is one of the very important things. This is in the AAN Practice Guidelines, and we do this as part of comprehensive MS care. You have to partner with the patient, so that they understand what you’re treating and you understand how they feel about the illness and the therapies. It’s a very important partnership because medication works only if people take it. They have to be on board, and they have to be properly informed of what you hope to realistically achieve with the efficacy, what the risks are, what the safety is, and how that fits in with their lifestyle.

One of the things we learned about 25 years ago when we would put people on interferon is that a year into the therapy, we asked, “Well, how do you feel?” and they said, “Well, I don’t feel any better. In fact, I feel worse because I’m taking this interferon, and it has adverse effects. What’s it done for me? I’m the same as I was.” We’d say, “Yes, you’re the same as you were, but you didn’t have any more attacks.” But it’s as if you’re taking away a negative. They wouldn’t necessarily feel better, but they also wouldn’t feel what they could have felt if they had more attacks. That becomes a part of the education process and having the conversation so that there are realistic expectations for the therapies.