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

Fred D. Lublin, MD: The prognosis of multiple sclerosis [MS] is extremely variable. We can now diagnose it very early. We can see people on their first attack, what’s called clinically isolated syndrome, which is actually the fourth subtype now. It’s their first attack of inflammatory demyelination, what’s going to be MS. Sometimes, we can’t diagnose it after that first attack. Usually, we can, unless there are changes on the MRI. But we have a pretty good idea of what happens to those individuals after that first attack if they’ve got certain changes on the MRI. We consider that the start of MS because that’s the clinical start.

We can go back even further and look at people who have had MRI [magnetic resonance imagining] changes, nothing clinical. They have an MRI scan because they had a bump on the head or a bad headache and the MRI looks like MS. We call that radiologic isolated syndrome because it looks like MS, but because they’ve never had a clinical event, we’re not prepared to diagnose them. We have studies that show if the MRI is characteristic of MS, then there’s a pretty good chance in the next 3 to 5 years that they’re going to have another attack or develop the signs or symptoms of multiple sclerosis.

Because we’re seeing people very early, we’re seeing a very broad prognostic range. We knew from autopsy studies in the past that there are some individuals who go their whole lives with MS and never know they have it. Now with MRI scans in this radiologic isolated group, we’re picking up some of those people. Some of them will go on to develop MS, some won’t. That’s the far left, the best side of the prognosis.

Relapsing-remitting can produce mild or severe disease, but the most severe disease we see is usually when people transition into the progressive phase, either secondary-progressive MS or primary-progressive MS. There you’ll see difficulties with ambulation and bladder, eventually upper extremity and swallowing. But our ability to predict this early on is very poor. We like to think that we can give people an idea of what’s going to happen, but we’re really not very good at it.

This has a practical implication because, with a range of therapies from pretty benign to very aggressive with potential safety issues, it would be nice if we were able to prognosticate really early on who was going to do badly. You would put them at more risk with a more aggressive therapy, but we’re just not at that stage yet.

Transcript edited for clarity .