The Brisk Evolution of Multiple Sclerosis Care

Publication
Article
NeurologyLiveNovember 2023
Volume 6
Issue 6

We are closer than ever to individualized management of MS, and keeping up with the rapidly changing pace of MS care is challenging even for an MS specialist.

GUEST EDITOR IN CHIEF

Rashmi B. Halker Singh, MD, FAAN Associate professor of neurology, Division of Headache Medicine, and director, Headache Medicine Fellowship Program, Department of Neurology, Mayo Clinic, in Scottsdale, Arizona

M. Alissa Willis, MD is an associate professor and the chair of neurology at the University of Mississippi Medical Center. She completed a clinical neuroimmunology fellowship and previously served as the medical director at the Mellen Center for Multiple Sclerosis at Cleveland Clinic. Her specific areas of interest include medical education, spasticity management, and the comprehensive care of patients with multiple sclerosis.

Willis graduated with a medical degree from the University of Mississippi School of Medicine, and then completed her internship and residency in neurology at the University of Mississippi Medical Center, after finally completing her fellowship in clinical neuroimmunology at the Cleveland Clinic Foundation.

Among her various accolades include the Cleveland Clinic Excellence in Neurology Award in 2019; the A.B. Baker Teacher Recognition award in 2018; a staff teacher of the year award in 2015; and neurology resident of the year award in 2011; and a medical student prize for excellence in neurology, a neuroscience critical care achievement award, and the Waller S. Leathers Award, all in 2007.

FEW AREAS OF MEDICINE are changing as rapidly as multiple sclerosis (MS) care. Prior to the 2001 McDonald criteria, the diagnosis of MS was a purely clinical diagnosis.1 Incorporation of MRI findings
to establish the diagnosis was a paradigm shift for neurologists at
the time. It would still take several years to establish MRI as a prognostic tool and a critical aid in evaluating response to treatment. It took several years to educate the neurology community about the value of MRI. This was happening in the context of discovery of antibodies associated with conditions that mimic MS.2 It is no surprise that misdiagnosis of MS is still common—more than 10% in a tertiary referral center.3

Revisions to the MS diagnostic criteria allow us to make the diagnosis of MS as quickly and accurately as possible, taking MS mimics into consideration. These criteria still rely heavily on a typical demy- elinating event, whereas emerging evidence suggests that the symptoms of MS may begin earlier than a defining episode.4 From many years of experience as an MS specialist, I can say that diagnosis
and even suspicion of MS in this prodromal phase is challenging. Symptoms overlap with other neuroimmune and systemic conditions. This leads to many clinical conundrums: Should we perform imaging for all patients who have fatigue or paresthesias regardless of examination findings? If the initial imaging result is normal, how often do we repeat imaging and how far do we go to make sure we do not miss someone who has a neuroimmune disorder?

Medical gaslighting was a new concept for me when reading this issue’s manuscript from Rachel Horne and colleagues. It is always important to balance medical knowledge with the patient experience. Although we have made significant advances in early diagnosis of MS and related disorders, there are things we still do not know. I look forward to biomarkers that will help us better identify persons at risk for developing MS before it happens. The possibility of diagnosis and treatment prior to accumulation of lesion burden and brain atrophy seems like a dream for someone who trained in the era of ABCR (Avonex, Betaseron, Copaxone, and Rebif) or platform drugs, initially available only through a lottery system. The advent of MRI, blood, and cerebrospinal fluid biomarkers places this within reach.

Advances in the diagnosis of MS have been accompanied by advances in treatment. The first MS therapy was approved in 1993. We now have more than 25 options for treatment. MS specialists have adapted the approach to treatment as we learn more about the pathophysiology and the risks of undertreatment. My personal approach to management of MS has changed since my fellowship training when we had few options available for treatment. We now have generic and biosimilar options available. New classes of MS therapeutics will be available soon.

We are closer than ever to individualized management of MS. Keeping up with the rapidly changing pace in MS care is challenging even for an MS specialist. I look forward to the day that we are talking about a cure rather than treatment.

REFERENCES
1. McDonald WI, Compston A, Edan G, et al. Recommended diagnostic criteria for multiple sclerosis: guidelines from the International Panel on the Diagnosis of Multiple Sclerosis. Ann Neurol. 2001;50(1):121-127. doi:10.1002/ana.1032/
2. Weinshenker BG, Wingerchuk DM, Nakashima I, Fujihara K, Lennon VA. OSMS is NMO, but not MS: proven clinically and pathologically. Lancet Neurol. 2006;5(2):110-111. doi:10.1016/ S1474-4422(06)70333-7
3. Wang Y, Rjeily NB, Koshorek J, et al. Clinical and radiologic characteristics associated with multiple sclerosis misdiagnosis at a tertiary referral center in the United States. Mult Scler. 2023;29(11- 12):1428-1436. doi:10.1177/13524585231196795
4. Marrie RA, Allegretta M, Barcellos LF, et al. From the prodromal stage of multiple sclerosis to disease prevention. Nat Rev Neurol. 2022;18(9):559-572. doi:10.1038/s41582-022-00686-x
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