Current Series: Treatment Of Multiple Sclerosis Relapses

Thomas P. Leist, MD, PhD: In multiple sclerosis [MS], we often wonder whether relapses have long-term consequences on patients or whether the term relapsing-remitting multiple sclerosis is truly appropriate. We know from ample research that the term remitting is probably not a completely correct term, because, following attacks, patients always have some things that are left behind. Sometimes it may be very little, and sometimes it’s more. We even see this in patients with optic neuritis where there is a decrement, for example, in color perception persisting even after they have recovered from the optic neuritis.

Why do we treat relapses with multiple sclerosis? Very often, we use corticosteroids or other interventions to treat the relapses. The goal is to shorten the relapse and also make the depth of the relapse less significant. There are obviously approaches in order to mitigate the impact of the relapse. In reality, what we really want to do is not have to relapse in the first place, and that’s where an appropriate disease-modifying therapy for multiple sclerosis comes into play.

Do relapses have impact on a person’s functioning above and beyond what we see, for example, with the impairment of motor function? Yes. At the time of a relapse, patients very often express increased fatigue. Sometimes, there are also mood alterations present at the time of a relapse. Lastly, we are always concerned with a relapse if there is an enduring deficit that is unmitigated by the length of recovery of the patient.

One of the challenges we have in multiple sclerosis is that the disease is so variable. At the same time, both payers and many practitioners would like to have a more algorithmic approach to the treatment of multiple sclerosis. What this will mean is that one indicates where to start and how to progress with treatment in individuals. What this also means is that options that address both patients with mild disease—patients with more beneficial properties on their MRI [magnetic resonance imaging] in their presentation—and patients with more aggressive disease, with more significant findings on the MRI or clinically, would have access to appropriate treatment from the get-go.

Currently, we often have the step edits from payers where older agents need to be approved and used first. Such an algorithmic approach as, for example, that presented by the Consortium of Multiple Sclerosis Centers [CMSC], would allow attribution of treatment to patients dependent on their disease-activity grade, severity grade, or the prognostic features that are present. In the end, one of the challenges that we face in multiple sclerosis is that patients very often come in with different and differing disease phenotypes, even in the earliest features. When we apply such algorithms as the one proposed by the Consortium of Multiple Sclerosis Centers, we need to keep in mind that one needs to implement this with the best interest of the patient and the long-term goal of reaching no disease activity in the patient as soon as possible.