Case-Based Considerations in MS Treatments

April 19, 2016

Interactive case study discussions highlighted the issue that treating multiple sclerosis often involves swimming murky waters.

“Does benign MS still exist?” Dr. Scott Newsome, DO of Johns Hopkins University, Baltimore, MD asked before diving into a cascade of emerging MS drug therapies at the American Academy of Neurology’s 68th Annual Meeting. MS is sometimes hidden, but never benign, he stated.

Following Dr. Newsome was a presentation by Dr. Myla Goldman, MD, MSc of the University of Virginia, Charlottesville, VA who cast a spotlight on some key problem areas in the treatment of multiple sclerosis. The case studies she presented offer strong support for Newsome’s thesis that MS is never benign - only hidden.

The interactive presentation literally allowed audience members to become participants in the discussion about three case studies. The iOS software she utilized allowed her to know instantly the response to her questions, shown in percentage.

She compared those outcomes with real-world data to demonstrate what choices physicians, including herself, have actually made with respect to the same questions.

Physicians and patients swimming the murky waters of multiple sclerosis have more than their share of questions to deal with, including:

  • if and when drug treatments should begin
  • if so, how aggressively
  • if and when to switch treatments

Dr. Goldman asked questions about each case that reflected questions physicians have to ask themselves when they make urgent choices. Her questions also pointed to the variability in cases, the fact that nothing is ever “black and white.” Below is the first case.

Case #1

A 37-year-old female Caucasian with an abnormal MRI. The MRI was obtained to evaluate headaches, but it revealed a lesion. She had no family history of MS.

The first question put to the audience was if they would start treatment. Although 60% of responders said they would do so, only 10% of patients in the United States with similar profiles are treated.

Next, participants who would start treatment were asked which kind of DMT they would prescribe. A low percentage made the same choice as Dr. Goldman when she was faced with the decision.

Dr. Goldman then asked the other participants (those who wouldn’t start a DMT) when they would order the next MRI. Forty-nine percent said in 6 months, while 6% said never. The rest were split between 12 and 3 months.

Besides demonstrating the difficulty in making the above kinds of choices with patients, a further problem surfaced.

Patients with abnormal MRIs, including evidence of white matter lesions (such as the patient above), show no other symptoms of MS. Although these lesions have the appearance, location, and distribution of MS, they are not accompanied with clinical MS symptoms.

hese patients get diagnosed with radiologically isolated syndrome (RIS). Not because the patient doesn’t have MS, but because it might be hidden.

“The river we are swimming in is clear as mud,” said Dr. Goldman with a laugh, “but if we swim really hard we just may end up swimming in a sea of clarity.”

Note: the patient in Case #1 had a clinical event within two years that further suggested MS.

From materials presented during AAN Annual Meeting in Vancouver, British Columbia. Session C44: Multiple Sclerosis Overview: Clinical Advances II. Apr 16, 2016.