Current Series: Multiple Sclerosis Relapses


Stephen Krieger, MD: One of the challenges is rolling out some of the things we’ve talked about today to the community at large. In particular, how can we think about having the optimization strategy that you’re presenting here being adopted by the community? One of the challenges is not everybody has all of those folks and a broad comprehensive care group of people around to bring to bear on the care for their MS [multiple sclerosis] patients. I would say that the lack of the staffing and expertise is 1 of the challenges.

One way to try to address it, if you’re in an area that doesn’t have all these resources, is to say, “Does the National MS Society have people in the area who can be a resource? Does the MSAA, the MS Association of America, have people in the area who can be a resource?” If you don’t have them all in your place or even in your Rolodex, the national organizations may have it in theirs. That’s 1 way of trying to take the strategies in your treatment optimization and get people to help with that in the community.

Samuel F. Hunter, MD, PhD: One of the things that I think is has been mentioned several times is the rural patient and how to address them. And we’ve actually done a thing that involves using not neurologists but urgent care physicians who operate urgent care centers, who want to provide urgent services for these patients.

We’ve gone through our algorithm of how to exclude infections, making sure this is a relapse. And you get these calls and it’s always the same thing. Did you check your urine? Did they seem like they’ve gotten anything wrong with them? Is their belly hurting? What gets overlooked and called an MS relapse is quite amazing. Everything from dental abscesses to acute abdomens. And you need to be safe about using steroids. But if you screen those things and you have objective things, I try to tell the guys, “Please examine the patient, please examine the patient,” because they’re so used to just rolling people through.

Examine the patient; write it down. You can treat them with steroids, have them come back and see me in a few weeks. I don’t need to know if you’re pretty sure. Because relapses are going to happen. When you see a patient with a relapse you can be guaranteed someday they’re going to have another 1. And the ones who have a lot, they’re going to keep having a lot on treatment.

But this is a great practical document, and it says, when you get to the end, start over if it’s still a problem. And the last thing I want to say is that you’ve got to not rely on MRI [magnetic resonance imaging] for assessing relapses. That has worked when you say, “I don’t know what on earth is going on with this patient.” That’s not the average patient with MS. You aren’t going to learn anything by doing an MRI. In fact, the harm often is that people who are not sophisticated about MS will say, “Oh, the radiologist says there’s nothing wrong.” Yes, sometimes they even tell them they don’t have MS. But they often say, “Well, nothing is enhancing, so you don’t have a relapse.” The patient can’t stand up. What do you think is going on? But this happens a lot, and it’s a waste of resources as well, and it’s better done when they’re convalescing a month or 2 down the road when you’re making decisions about how I’m going to manage a person in the future rather than manage relapses.

Stephen Krieger, MD: That’s a great point. Well, I appreciate your punchline takeaway points. Amy, do you have a punchline takeaway from this discussion of relapses that you’d like to share as well?

Amy Perrin Ross, APN, MSN, CNRN, MSCN: Well, I think the key points that have been made is that there are tools out there now such as the ARMS [Assessing Relapse in Multiple Sclerosis] tool that can help our colleagues—help colleagues in my office and colleagues around the world—assess a relapse in a consistent way. There’s now an algorithm based on a clinician expert opinion to talk about guiding treatment, and then a follow-up assessment to, as Sam says, be the starting point where we start all over. These are good resources for us. They’re good resources for people who manage patients with MS, and hopefully they’ll get utilized.

Stephen Krieger, MD: That’s great. Thank you. Dr Berger, closing thoughts from you.

Joseph R. Berger, MD: My closing thought is the following. Our stroke colleagues use the term time matters. I think the MS neurologists, among others, should use the phrase relapses matter. Why do relapses matter? They’re indicative of activity as both Rob and Sam mentioned. Particularly frequent relapses early in the course of the disease are predictive of ultimate disability. Certain relapses, such as motor relapses, cerebellar relapses, and likely sphincter relapses, are predictive of disability.

And the thing we want for patients, and the thing that’s of paramount importance to our patients, is they don’t want to be disabled. If they’re temporarily inconvenienced, it’s 1 thing. But if it is predictive of disability, we want to know about it. And relapses are telling us that this disease is active, and therefore we have to start thinking about what we need to do about it other than what we’ve done previously. It has predictive value, and there’s a reason that annualized relapse rate has been incorporated in virtually every clinical trial that we’ve done for disease-modifying therapies. So my comment is: relapses matter.

Stephen Krieger, MD: Perfect. Robert?

Robert Bermel, MD: I’ll underscore the importance as well, because I think identifying relapses correctly—separating them from things that we may call pseudo-relapses or call-symptom recrudescence or whatever the terminology is that you like to use—becomes very important. Relapses do have importance for not only the disability that may come with that individual relapse, and the need for treatment and recovery, but long term, what does it indicate? It indicates disease activity and that should be a signal to the care team that some decisions need to be made. And I think MRI can be helpful and follow up with that to lend an objective lens to whether or not the person has had interval disease activity that’s visible in MRI. And I think that in that frame of relapses, new MRI activity should signal potentially a different strategy for disease-modifying therapy. That’s usually all subsequent to cleaning up after the mess that’s happened with the relapse, including the multidisciplinary care team or local resources that need to be leveraged for that. So it is important. You’re exactly right, Dr. Berger.

Stephen Krieger, MD: Well, this is great. I have no real final point of my own to make except to say that disease activity matters. And I think we look for disease activity now across the spectrum of multiple sclerosis. Disease activity is the expression of relapse, and relapse is the expression of disease activity. It still remains an unmet need.

I really appreciate all your insights. I want to thank our entire panel. I want to thank you for joining us. We hope you found this Peer Exchange discussion to be useful and informative, and thank you for watching.