Future Directions in Treatment of MS Relapses

Regina Berkovich, MD, PhD: I think neurology is such a field where the different disease states range from a disease state when no treatment options are available at all to MS [multiple sclerosis], where multiple treatment options are available; that can be confusing. I understand when general neurologists may feel somewhat skeptical about the success we have in the field of treating MS. I would say the best thing for a patient living with MS is to be seen by an MS specialist. I think that it probably would be my most sincere advice. Do this for your patients. Allow them to see an MS specialist at least once or twice a year so we can update the patients on the new treatments available in their personal response to their current treatment.

I’m sure general neurologists may not have enough time to review the MRIs [magnetic resonance imaging] with the patients, but this is what we do, at least I do that. I explain to the patient in front of the MRI, and in reviewing all the clinical presentation, I evaluate if it is a good idea to remain on the current disease-modifying therapy or if it is a better idea to switch. If the switch is recommended, what options are out there? I think it is the best service to give patients with MS access to the experts.

The number 1 barrier I would see in adopting the new algorithms, treatments, and knowledge of different options of disease-modifying therapy in multiple sclerosis is time limitation. General neurologists are dealing with many different disease states. And we are in a position where more pressure is being positioned on neurologists, and more demands and decision making—review of MRIs, discussion of the outcomes—seem to be added on top of everything else we need to do.

Because the treatment of MS is getting so complex, I think it’s not fair to expect general neurologists to know all the minor details of the management of MS and a review of the outcomes on a regular basis. I think that this is a challenge, that the field evolved and developed so much that it’s becoming more complicated. At the same time, the neurologist is expected to see more patients within a day, which is not something that you can offer patients with MS and expect this patient to be treated at the top level of available therapies and options.

I cannot spend less than 40 minutes with my patient for the follow-up. The new patient would require close to 90 minutes, and this is how long it takes. Can we expect every general neurologist to dedicate so much time? Probably not. It is not realistic because unless it’s done in such an intense in-depth way, we may not have the best outcomes. That’s why I would encourage my colleagues to consider using our expertise when it comes to consulting patients, even if it is once a year for the review of the MRIs and discussion of the outcomes of treatment.

We hope that the outcome measures will help us see the future. Whenever medication is approved based on the 2-year long clinical trial, we obviously would like to know how this medication is likely to work for much longer. This is because we talk about having a nearly normal life expectancy in patients with MS, and we anticipate them to remain on those medications for longer than 2 years. Therefore, some of the outcome measures should help us understand the future directions this medication may take us if continued. In that respect, the studies in brain volume are going to be very helpful. I see it as a new tendency in including more volumetric studies in the protocols of the clinical trials.

Another thing that is very challenging but exciting at the same time is attempting and seeing confirmed disability improvement in the clinical trials. We used to think about long-term therapies for MS as tools to slow down progression. But the question our patients were asking repeatedly was, “But, can I see improvement?” That is a very important question indeed.

Some of the mediation as a post hoc analysis implemented the evaluation to see if patients did show improvement and if so, how reliable those data are. Mind you, those are post hoc analyses. They were not primary outcomes in those clinical trials. Nevertheless, I see it as a very good tendency and reason for optimism that we hope to see improvement in the long-term outcomes when it comes to the disability. Obviously, more studies and longer studies are necessary to make us feel confident about it.