Clinical Insight on Challenges and Evolving Strategies in Advanced Multiple Sclerosis Care

Sam Hooshmand, DO

(Credit: Medical College of Wisconsin)

The Whitaker Track Invited Lectures session, MS in Special Populations, presented at the 2025 Consortium of Multiple Sclerosis Centers (CMSC) Annual Meeting, held May 28-31, 2025, in Phoenix, Arizona, offered a comprehensive look at the unique challenges and considerations in managing multiple sclerosis (MS) across diverse patient groups. Chaired by Ahmed Zayed Obeidat, MD, PhD, the session featured Sam Hooshmand, DO, who discussed clinical approaches to advanced MS and the impact of functional decline on care strategies.

During the session, Yinan Zhang, MD, MS, explored the intersection of aging and MS, emphasizing the growing relevance of gerotherapeutics in this population. Following a short break, Grace Gombolay, MD, MSc, highlighted both the progress and persistent unmet needs in pediatric MS care. The session concluded with a panel Q&A, facilitating interdisciplinary discussion on tailoring MS management across the lifespan with experts in the field.

After the presentations from the session at the meeting, Hooshmand, assistant professor of neurology at the Medical College of Wisconsin, had a conversation with NeurologyLive^® to further describe the challenges clinicians face when identifying and managing advanced MS. He noted the absence of a standardized definition for advanced MS and the limitations of relying solely on Expanded Disability Status Scale (EDSS) scores. Hooshmand also emphasized the burden of secondary complications and the limited inclusion of patients with advanced MS in clinical trials for disease-modifying therapies (DMTs).

NeurologyLive: How would clinicians typically define and recognize the transition into advanced MS in clinical practice?

Sam Hooshmand, DO: One of the challenges about understanding the transition to advanced MS is that there's no standardly accepted definition for advanced MS. Clinicians typically rely on a combination of factors, including level of functional disability, symptom burden, and loss of independence. In the past, physicians have really relied on the EDSS, with scores above 6 indicating advanced MS, as those patients need to rely on a walk aid to help ambulate. However, this doesn't take into account other factors, as the EDSS is heavily weighted towards lower extremity functioning. These include symptoms such as bladder and bowel issues, cognitive dysfunction, and sensory loss.

What are the biggest challenges in managing symptoms and maintaining quality of life for patients with advanced MS?

One of the biggest challenges for managing symptoms in those with advanced MS is the secondary complications in terms of infections patients have from their sequelae of MS syndromes. One of the biggest ones is respiratory tract infections, which, from an infectious standpoint, account for over 50% of deaths from infection in advanced multiple sclerosis. These are often because of brainstem syndromes that lead to aspiration pneumonia. So, physicians need to particularly inquire if patients are having trouble with coughing, gasping, or sputtering whenever eating or drinking.

Along with that, urinary tract infections can be a big risk of sepsis in the advanced MS patient population, and we need to watch out for patients with difficulty emptying their bladder. Immobility can lead to wounds and secondary infections, and we need to really make sure our patients have the proper equipment—whether it's ergonomic seating or modifications to their wheelchair. Ultimately, symptomatic management in MS is aimed at allowing patients to have the most functional independence and best quality of life.

How has clinicians’ approach to treatment evolved for patients in the advanced stages of the disease, particularly with regard to DMTs?

One of the particular challenges when looking at DMTs in advanced MS is that all the pivotal clinical trials that led to the DMT approvals have excluded patients with advanced MS, as they're usually capped at an EDSS of 5, 5.5, and in some of the recent trials, at 6.5. This really makes the discussion on DMT implementation and withdrawal personalized and individualized, where we have to weigh the benefits of the DMT—which mostly help with the inflammatory phase of MS—against the risks, particularly infectious risks.

So advanced MS is a particularly challenging entity, and we as neurologists need to advocate and work with our industry partners to try to include these patients in clinical trials to get the data we need to make better decisions in terms of disease-modifying therapies.

Transcript edited for clarity. Click here for more coverage of CMSC 2025.

REFERENCES
1. Hooshmand S. Advanced Disease States in Multiple Sclerosis: A Clinical Perspective. Presented at: 2025 CMSC Annual Meeting; May 28-31; Phoenix, AZ. Whitaker Track Invited Lectures: MS in Special Populations.