Fred D. Lublin, MD: This has been extremely informative. Before we end the discussion, I want to ask each of you to give us some final thoughts regarding where we are in early 2019 with multiple sclerosis [MS]. Dr Coyle?
Patricia K. Coyle, MD: This is a very exciting time. We have a multitude of disease-modifying therapies for relapsing MS. We recognize critical is early treatment, effective treatment, and shared decision making, as well as following patients closely. Do not forget wellness. Emphasize that. That’s important. That helps CNS [central nervous system] reserve. Do not forget comorbid conditions influence and damage the central nervous system, many of them. They must be optimally controlled. Lacking—we need effective CNS repair, and we need to figure out the puzzle of progressive MS and have neuroprotective treatments for neurodegeneration that probably will need to be started at the very earliest MS time point. But we’ve made tremendous advances. This is very exciting.
Fred D. Lublin, MD: Good. Dr Dhib-Jalbut?
Suhayl S. Dhib-Jalbut, MD: To me, the most important unmet need is treating progressive disease. Taking treatment in all forms of MS to the next level, just like oncologists do, we need to look at combination therapy and look at induction therapy followed by maintenance therapy to see if those would really impact the course of the disease in the long run. And I think we need to, again, advance the area of personalized medicine in MS. We need to develop biomarkers to predict the course of the disease as early as possible. And, once you start the patient on treatment, we need to be able to predict the response to treatment within a short period. If you know that drug is not going to work for this patient, you make that switch early on.
Fred D. Lublin, MD: Dr Leist?
Thomas P. Leist, MD, PhD: There is an early window in multiple sclerosis, in my opinion, that we don’t fully utilize, partially because we may not fully appreciate what it means to incur injuries during that window, and partially also because we may not have access to the full armamentarium of medications that have been developed for the treatment of multiple sclerosis. MS is also a disease that needs regular reevaluation of the patient, with new treatment decisions being made when the patient shows progression. So it is, in my mind, not acceptable if patients are on a single agent long term and slowly but surely deteriorate on these agents, whether or not they have overt activity attacks.
Fred D. Lublin, MD: Dr Markowitz?
Clyde E. Markowitz, MD: I’m going to agree with everything that’s been said. I think the approach that we have lived for the first 20 some odd years of therapeutics in MS has been OK. I think we need to go much more aggressively up front. I don’t want to call myself an oncologist, but I feel like I’m moving into that conversation. And we need to be able to come up with strategies that are safe, so that we don’t have as much of a concern on the safety side of things. That being said, 1 piece that has not been addressed, and we didn’t talk about this at all today but I think it is a very exciting area, potentially, is the microbiome. I think there’s a lot there that we have not yet uncovered and it could really answer a lot of the concerns that we have. And I think it’s going to be the next decade’s worth of research.
Fred D. Lublin, MD: And Dr Stankiewicz?
James M. Stankiewicz, MD: The further we go along the line here, the harder and harder it gets to say something really interesting. But I would agree with all the comments that are made. I would just emphasize that it really is exciting to be part of this community because there have been so many discoveries along the way. The meetings have so much energy, which people bring, and we see so much hard work. People really are thinking about how to make this better and better for patients. In the time that I’ve had the opportunity to diagnose patients, I’ve never looked at it as a fatal sentence. I think that we are very capable of managing patients and really changing their disease course. Of course, there’s room to get better, but I think there’s a lot of hope.
Fred D. Lublin, MD: Indeed. So these are very exciting times in multiple sclerosis, which has been leading the area of neurotherapeutics, which is growing excitingly, and not just for MS but for other areas of neurology as well. And I suspect we’ll continue for quite a bit longer. So thank each of you for your contributions to the discussion. On behalf of our panel, we thank you for joining us, and we hope you found this Peer Exchange discussion to be useful and informative. Thank you all.