Clinical Pearls for the Management of MS


Expert neurologists emphasize the importance of conversations around patient lifestyle, mental health, and comorbid conditions as keys to improve care for MS.

Ahmed Z. Obeidat, MD, PhD: I want to thank you both a lot. This has been a great discussion. I want to give you the opportunity to share your final thoughts. I’ll start with Dr Berkovich. What are your final thoughts and messages that you want to summarize or give to our audience?

Regina Berkovich, MD, PhD: What I’d like to say isn’t something you’d expect from a pharmacologist or MS [multiple sclerosis] specialist with a pharmacology background, because it isn’t related to the treatments. In our day-to-day communication with patients, we should remember that a lot of responsibility lies on our patients’ shoulders. If we don’t see optimal response to therapies, even if we use the highest efficacy medication, we need to look at the patient’s habits. If my patient is complaining about not getting the outcome they were expecting from the medication, and I can smell tobacco in the examination room, then I know the answer. It’s right there. Please don’t hesitate to address it.

If you have a patient who complains about overwhelming fatigue and you appreciate that this patient is at least 300 lb, please speak up. Because if done nicely and tactfully, it will help patients, won’t really irritate them, and can help to improve their lives. I have patients who went from 300 to 200 lb, and their life improved tremendously. In fact, they’re very grateful that we had this conversation years ago. It was maybe not very pleasant for them, but it helped them address a huge problem.

If the patient is dehydrated, if you see a patient who has been treated seemingly successfully but doesn’t show any improvement, and is dealing with chronic UTIs [urinary tract infections], maybe dehydration is one of the reasons. Maybe because of the neurogenic bladder, this patient drinks only 3 glasses of water per day. This patient can’t improve no matter what therapy you put them on. They need to step up and drink 10 glasses of water. I tell those patients, “Go to a store, buy 10 glasses, fill them up with water, and put them on the counter. That’s what you need to drink through the day. Until you have that gulped down, you can’t go to sleep.”

Ahmed Z. Obeidat, MD, PhD: These are great and practical points and very helpful to our audience. The way to talk to patients and address those factors, and focus on the whole person and everything surrounding them is very important. Dr Hendin, any final thoughts or messages to our audience today?

Barry A. Hendin, MD: I have 2 thoughts. One echoes Regina’s, which is that we aren’t doing a sufficient job if we think that our job is solely using the disease-modifying therapies, or even the symptomatic therapies that make life better for patients, dealing with things like their gait, depression, or anxiety. We have disease-modifying therapies. We need to think about symptomatic medications to make people’s lives better today. As Regina pointed out so correctly, unless we’re dealing with wellness and general medical health, we’ve failed them and failed collaboratively. It means that I’m always addressing tobacco when it’s there. Exercise and encouragement is important. Exercise for general health, psychological health, and fatigue. Weight reduction is important, I don’t have a magic diet, but obesity is an enemy; so keeping them lean by a generally healthy but not punitive diet.

It’s also important that they maintain their social contacts, they don’t lose their connections, and that we address their mental health issues. Depression and anxiety are a huge part of MS. Even then, we aren’t doing enough if we fail to address their uncontrolled diabetes, uncontrolled hypertension, or uncontrolled cardiovascular disease. The optimal care of a patient with MS relates to their psychological status, social situation, wellness, and medical health, and we’re only a part of that collaboratively.

The last comment is about how far we’ve come and how optimistic that is for the future. Ahmed, you alluded to how long I’ve been a neurologist. I’ve been a neurologist since 1972. There was no CT scanner in America the day I left training, much less an MRI scanner. I had to wait another 20 years for the first disease-modifying therapies. Now we’ve got more than 20, with a bunch still on the way. Of the things I held to be true, some were true, many were half true, and many were wrong. We’re learning. I don’t want anyone to have MS or any other neurological disorder, but we’ve done so much better that we can tell people with the diagnosis of MS today something very hopeful: the hope for a life without significant disability. We’ve got the tools, and increasingly, we’ll be developing those tools. Those are my parting 2 thoughts; one of which is entirely Regina’s, and the other is a statement from someone who has been doing this for a long time and remains very excited about the future.

Ahmed Z. Obeidat, MD, PhD: We appreciate all these great comments. Our audience appreciates this. Both of you touched on the importance of managing comorbidities and paying attention to them as we look at having a successful journey with MS. The ACTRIMS [Americas Committee for Treatment and Research in Multiple Sclerosis meeting] opening lecture was on comorbidities in multiple sclerosis. It was very inspiring to see that this is something to also incorporate in your practice, and trying to help patients change some of the things that you may not think are ideal, like decreasing weight or stopping smoking, and other aspects of lifestyle and things that you’d talk to your patients about.

This is very educational to our audience as they think about how we also talk to our patients in the clinic. We should always be doing this, and addressing mental health, well-being, and nutrition. We should be addressing all of this and not forgetting about the importance of disease-modifying therapy, and highly effective disease-modifying therapy early after diagnosis. People ask, “When do you start disease-modifying therapy?” It’s when you diagnose MS. That’s what we try to do. Sometimes that’s where the delay may happen. This is why we combine disease-modifying therapy with all the other approaches to have as much success as possible treating and managing MS and having a successful journey living with this disease.

I can’t thank you both enough. We’ve had a rich and great discussion. I enjoyed it a lot, and I’m sure our audience enjoyed this. Thank you again. To our viewing audience, we hope you found this NeurologyLive® Peer Exchange discussion to be useful and informative. If you enjoyed the content, please subscribe to our e-newsletter to receive upcoming Peer Exchanges and other great content right in your inbox.

Thank you both very much. It’s great having you and seeing you all.

Barry A. Hendin, MD: Thank you. It has been a pleasure.

Regina Berkovich, MD, PhD: Thank you.

Transcript Edited for Clarity

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