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Challenges and Solutions in the Management of Multiple Sclerosis - Episode 1

Comorbidities in Patients With Multiple Sclerosis (MS)

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Stephen Krieger, MD; Daniel Bandari, MD, MS; Bruce Hughes, MD; Mitzi Williams, MD; and Heidi Crayton, MD, discuss the prevalence of comorbidities in patients with multiple sclerosis.

Stephen Krieger, MD: Hello, and welcome to this NeurologyLive® Peer Exchange titled, “Challenges and Solutions in the Management of Multiple Sclerosis.” I’m Dr Stephen Krieger from the Icahn School of Medicine at Mount Sinai in New York, New York. Joining me today in this discussion are 4 of my colleagues. Dr Daniel Bandari is the director and the founder of the Multiple Sclerosis Center of California clinic in Laguna Hills, California. Dr Bruce Hughes is the director of the Ruan MS Center, and associate professor of neurology at Des Moines University College of Medicine in Des Moines, Iowa. Dr Mitzi Williams is a neurologist and MS [multiple sclerosis] specialist. She is the founder and medical director of Joi Life Wellness Group in Atlanta, Georgia. And Dr Heidi Crayton is the medical director of the MS Center of Greater Washington and assistant professor of neurology at Georgetown University Hospital in Washington, DC. Welcome to our panel.

Our conversation today will focus on discussing comorbidities in MS and specifically, the use of S1P [sphingosine-1-phosphate] receptor modulators for MS treatment. We’ll also discuss data on sequencing of disease-modifying therapies, new challenges, and our approaches to guiding patients through treatment discontinuations. So welcome, everyone. We’ll get started with our panel.

In the real world of MS practice, patients aren’t always as homogenous as they are in our clinical trials; we have to think about real-world issues and comorbidities. So, let’s start by thinking about comorbidities in multiple sclerosis. Let’s think about the prevalence of real-world other illnesses and how we navigate that. Dr Williams, do you want to talk about what the population in Atlanta is like, and what sort of comorbidities you’re taking care of?

Mitzi Williams, MD: Absolutely. I live in an urban city in the southern part of the United States, and I have a very large proportion of patients of ethnic minority backgrounds, particularly of African American descent. And we do see a large amount of comorbidities such as hypertension, diabetes, and hypercholesterolemia. And so, it’s increasingly important for us to pay attention to these comorbidities because as our treatment landscape expands, there may be interactions with certain medications. We also have to be aware of any heart conditions because these may cause issues with our medications. I’ve become increasingly aware of this, making sure that we have accurate medication histories, as well as making sure our patients are checking up with their primary care physicians, so that if there are comorbidities that need to be addressed, they’re treated appropriately.

Stephen Krieger, MD: It’s really important. Some of those are exclusions for our clinical trials. In real life, we don’t get to exclude our patients on the basis of comorbidities, we have to take care of them. Looking across the country, Dr Hughes, Des Moines, Iowa, is a different population, but what kind of challenges with comorbidities are you facing with the people you take care of?

Bruce Hughes, MD: Similar to what Mitzi said, I think vascular risk factors across the United States are always very challenging. There’s a preponderance of data about how important controlling vascular risk factors is in treating patients with multiple sclerosis, including tobacco cessation, things along those lines.

Stephen Krieger, MD: That’s a good point too. Dr Crayton, do you do that management yourself? Or do you refer it entirely to the internist? How do you collaborate for that kind of comprehensive care?

Heidi Crayton, MD: I think that probably for all of us, our patients oftentimes view us as their primary care physicians. I find myself doing a lot more of that than I thought I would as a neurologist. Sometimes when there are some more involved issues, I do urge my patients to check in with their primary care physician, and even for some of the routine monitoring, things that really should be done as part of primary care. So, a little of both.

Stephen Krieger, MD: A bit of both, that makes sense. It’s probably similar in my practice as well. Dr Bandari, thinking about the comorbidities your patients have, does that influence how you start to treat their MS itself, their disease-modifying therapy selection? And do you talk to your patients about that?

Daniel Bandari, MD, MS: The answer would be yes. I think one of the main elements that’s going to make a tremendous difference is the fact that, at the end of the day, we want to make the best decision for that particular patient. I call it personalization of medicine.

A big factor, as all the colleagues have mentioned, is some of these comorbidities may be hidden from us. And unless we ask about them, and we know when they’re properly managed or not, for example, if somebody has a moderate level of diabetes, and we don’t know about their kidney function, whether they’ve been properly managing it, that’s going to have an effect as far as the clearance of whatever medication we’re using. Or transaminases and liver function, for example, are big factors. So, I put all of those into consideration, knowing the fact that the individualization of this medication depends on what kind of clearance we’re going to have for them.

And lastly, the concomitant medications they’re on sometimes can affect inhibitions or the proper enhancement of the treatments. I think it’s really important to make sure we have a complete list of whatever medications other doctors have given them in order to make that decision as well.

Stephen Krieger, MD: That’s great. As much as I don’t like when the electronic medical record pops up a warning to me when I prescribe something, sometimes these cross-checks of medications are quite useful, particularly if our patients have, for instance, antiseizure medicines, membrane stabilizers that they might be on for pain or other symptoms, or seizures. The way these affect the metabolism of other drugs is relevant.

Transcript edited for clarity