Current Series: Multiple Sclerosis Management

Fred D. Lublin, MD: So I’m glad the 2 of you stressed shared decision-making because this is complicated therapy. I’m thinking the American Academy of Neurology wisely recommended, in their treatment guidelines, 2 visits—1 for a diagnosis and then a second visit to go over therapy. Because it’s a long discussion. It’s a very long discussion. I think that a lot of the individuals come in, and they’re pretty well informed and bright, but with a lot of preconceived notions.

For example, we’ve had a lot of people come in, and when I start the therapy discussion they’ll say, “How long has that drug been around?” Which means that they’re more concerned about safety than they are efficacy, and it skews the discussion. We have people who we start on less aggressive therapies because they want something that’s been around for a long time and is safe.

Now, having the grayest hair here, I can tell you that I have people who’ve done perfectly on our earliest therapies. People were started in the early 1990s when interferon was around and nothing happened to them all along. So we know that there are people who do well on every one of the therapies.

What troubles me is that I can’t adequately apply the prognostic factors that Tom listed on an individual basis. On a group basis, it’s pretty clear. But I don’t know about it for the individual. And then, the other part to that is, how do we define a failure or an inadequate response? And we don’t have good definitions for that. The comparative efficacy data that we have, the good comparative efficacy data, are none of the information you are interested in. Right? You don’t care if the latest drug that comes out is better than one of the interferons. That’s not part of your decision-making process. Right? You want to know how this highly effective drug compares to this highly effective drug, because they may have different safety profiles. And I think we’re trying a variety of ways to get at that information, but none of them are particularly satisfying.

Thomas P. Leist, MD, PhD: If I may, there is another picture to all of this and it goes back to what Clyde said when he said, “I’m becoming a little bit more concerned early on in patients with my interventions.” Another concept is the fact that in our practices we see the patients that have been doing well over long periods of time. We no longer see the patients that have not been doing well because they are in nursing homes or they are no longer following up with neurologists. So the disease severity, the actual severity of MS [multiple sclerosis], is sometimes underappreciated because patients with more advanced multiple sclerosis deafferent from a neurologist and are no longer seen in these practices.

Clyde E. Markowitz, MD: That’s a good point.

James M. Stankiewicz, MD: And I think another point along these lines is, what is our target of treatment? I would make the argument that our goal really should be to preserve the normal aging process—to keep people as close to normal an aging process as possible, if we’re really doing our jobs, and not to prevent people from hitting an EDSS [expanded disability status scale] of 3 or 2. I think we really want them to be as close to normal aging as possible. And I think my concern is a lot of what Clyde has said: That you see patients that when they hit their 40s and 50s, cognitively they feel slower, they’re having more gallbladder symptoms, more mood symptoms. And I think it’s more than what you would expect just for age, and you see it over and over again, and you feel like you had missed a little bit the opportunity.

Patricia K. Coyle, MD: Well, if you’re really going to get that result, you need to make sure they’re not overweight, they’re regularly exercising, they’re not smoking, they’re getting good sleep, they’re really following a wellness program, and they’re getting their hypertension optimally treated. They have to look at the whole body. They have to take care of the whole body if they’re really going to age well.