Stephen Krieger, MD: To pick up on the point about the prognostic importance of relapses, we’re going to talk a lot in the rest of this program about how we assess and treat relapses. Let’s talk a little bit about why we do that. From the prognostic point of view, Dr Hunter, what’s the importance of relapses? Why are we treating them? How do they contribute to clinical course? Give us a mandate to try to shut down that inflammation.
Samuel F. Hunter, MD, PhD: Relapse is essentially the clinical correlate of inflammation in an important pathway in the nervous system. Most of what people notice goes on in their cerebrum. They don’t have specific symptoms from that. Very small areas of abnormality in new or old lesions in pathways, the optic nerve, the brain stem, the spinal cord, will produce most of the syndromes that we see clinically that present as relapses. Now, we have ways of looking at prognosis from a prospective point of view and ways in retrospective. And prospectively, we know that pyramidal and cerebellar are more disabling relapses in practice. Things that involve the bladder probably are as well. It takes much more severe sensory or visual deficit to be quite disabling, and we have a hard time measuring cognition. But it’s often along for the ride with these others.
Retrospectively, we recognize what a bad relapse is because it doesn’t improve in disability, and we have a love-hate relationship with this word remitting, because remitting actually just means it gets stable. It doesn’t mean it improves. And it is very important to explain to patients the nature of these events. But we don’t know until long after the onset of a relapse event, how much it’s going to improve. And things that don’t improve have very big significance early in the disease. And as Rob was talking about earlier about the difference between untreated and treated MS [multiple sclerosis], there’s a huge difference in how well people recover when they’re on treatment and when they’re treated versus when they’re not on treatment and they’re not treated, as well as when they’re treated. And we have clear evidence-based research about the rule of managing these events with pharmacotherapies.
Amy Perrin Ross, APN, MSN, CNRN, MSCN: I remember back in the hot-bath days, Joe…
Joseph R. Berger, MD: We’re probably the only 2 on the panel who remember that.
Amy Perrin Ross, APN, MSN, CNRN, MSCN: I think you’re right. Back in those days—even before we had disease-modifying therapies, or when we had some of the early ones but didn’t think our patients were “bad enough” to use them—all we could do for our patients was treat relapses. And we would treat everything that came along. Sometimes it was tingling in a finger; we’d better treat that. Other times, we didn’t treat it, and we were aghast if patients chose not to have treatment back then. But I think, Sam, you bring up a good point in terms of looking at if treating relapses matter. That’s a controversy that has been brought up in more recent times. Do relapses matter? And I would have to agree with you that, yes, they do from an inflammatory perspective in the ultimate outcome. They really do.