Future of Cognition in Multiple Sclerosis

Ahmed Obeidat, MD, PhD; Randall Schapiro, MD, FAAN; and Jeffrey Wilken, PhD, share their hopes for the future of multiple sclerosis treatment and discuss unmet needs and novel targets.

Ahmed Obeidat, MD, PhD: This is kind of an overview. We talked about the past, we talked about the present, now we’re going to talk a little bit about the future. Here, I’ll start with you Dr Schapiro and talking about the future of cognition and MS [multiple sclerosis] and where do you see this going, and even in relation to medications, but also in relation to biomarkers? I know we discussed this a little bit, but what do you see for the future?

Randall Schapiro, MD, FAAN: Well, I don’t know what the future will be with biomarkers, but I think there probably will be a future, and I do know that the future is brighter within cognitive issues because we have better drugs to preserve the brain and that’s what it’s all about—it’s about preservation. Until we have a way to reintroduce myelin into the central nervous system and reintroduce, not just myelin, it has to be nerves because the axons themselves degenerate— I’m not thinking that way. I’m thinking about preservation, and we’ve gotten better and better with it as we’ve gone along. And I can say that because I’ve seen it from my childhood all the way to how old I am now, it’s changed dramatically and I think it’ll continue to change as we get better, so I’m very hopeful about it. But actually treating that exact symptom with a symptomatic drug, I wish it were the way it was on television where they say “I took this drug and now I can do this, and that, and the other,” but doesn’t work that way in my opinion.

Ahmed Obeidat, MD, PhD: Dr Wilken, for future biomarkers and medications, how do you see the future of MS in relation to cognition?

Jeffrey Wilken, PhD: I think that, with respect to the medication issue, as Dr Schapiro was saying, we’re certainly going to see as the medications become more effective, that that’s got to have an effect on cognition, I think, over time. I think we’re going to see more and more, whether for better or for worse, polypharmacy, where, maybe the better polypharmacy kind of thing here - the better outcome I mean, insofar that maybe if we can treat some of the fatigue, treat some of the depression, then, that we can see improvements in cognition. What I would like to see for the future in cognition though on a more practical research sense, is for this MS community of scientists who finally agree on a marker, on a test that can be used fairly easily, if it is SDMT [Symbol Digit Modalities Test] or something else, it doesn’t matter to me— that can be used fairly easily across clinics, that can be something that the FDA [Food and Drug Administration] would consider approvable as an end point, because if you have that, then what you’re going to have are more studies done, because then the funding organizations are going to say “OK, they can do something with this,” and until you have that, it’s so hard to get consistent, repeatable studies with this and studies that are done that are specifically looking at cognition, not just add-ons, not just phase fours, but actually looking at cognition early on in the manufacturing of the medication to see what can be done to help this person. And then finally, I think we’re going to just see more and more good research on cognitive rehabilitation. That needs to come together too. As I said, there’s some good research out there, but let’s see which programs are the best. What is actually helping people the most? Because right now, it’s still a variety of different programs. Maybe they’re all helpful, maybe it’s what we’ve been talking about before, and you just need to keep your brain active, but let’s see.

Ahmed Obeidat, MD, PhD: I’m always intrigued, and I think it’s interesting what they do with some video gaming and virtual reality … mention of, oh, this is kind of fascinating.

Jeffrey Wilken, PhD: Yes, it’s one of the areas of cognitive rehabilitation that has come a long way. They call it gamification I think—

Ahmed Obeidat, MD, PhD: Yes, gamification is—

Jeffrey Wilken, PhD: - and you know what, people enjoy that, they have their cell phones with them all the time, but let’s see how well they work. There’s some good evidence, but again, it’s not the class one data yet, we need to see some better—

Ahmed Obeidat, MD, PhD: This is more, kind of like, keeping people engaged, even if they’re engaged with a screen, but they’re engaged with a screen where it’s interactive maybe.

Jeffrey Wilken, PhD: Well, and they’re thinking.

Ahmed Obeidat, MD, PhD: And they’re thinking right? And they can have it wherever they go, right, nowadays, right?

Jeffrey Wilken, PhD: Might as well use the phones for something good.

Ahmed Obeidat, MD, PhD: That would be one thing, yes. Also, now to your point that you mentioned, that really, something or a biomarker, or even a marker or a test, that can be used clinically and not only just for research purposes but really can be used easily in the clinic is something that may change the future, right? Because then we’ll actually have more data, we’ll be able to measure the efficacy of our treatments, and then incorporating all these symptomatic medications. And to me, polypharmacy is one thing I always struggle with; why do we have this whole list of medications and when I evaluate a medication list, I think, “Which one can I take away?”

Randall Schapiro, MD, FAAN: Good side and the bad side.

Ahmed Obeidat, MD, PhD: That’s right because sometimes can be …a balancing act.

Jeffrey Wilken, PhD: Well, hey, you can give a person a lift with a drug that affects fatigue, if you take it too late in the day, they’re not sleeping, so I mean, it’s such a balancing act.

Jeffrey Wilken, PhD: When I see the polypharmacy list I get from some of my patients, it’s not like I think “Why is this neurologist doing this?”, I think, “I feel bad for that neurologist trying to figure out which of this is the right —”

Randall Schapiro, MD, FAAN: And it’s not just the neurologist because the people have other things going wrong with them too, so they have other drugs for this, and that, and the other and … you’re right, it gets to be wild.

Ahmed Obeidat, MD, PhD: Sometimes, cognition can be affected by just that … pharmacology -

Jeffrey Wilken, PhD: I had a neuropsychology case, it was not a patient with MS, but it was so clear based upon that polypharmacy, the person was literally falling asleep at times, so we had a discontinuance. I said, “If you want this person tested again, you need to look at this list of medicines first.”

Ahmed Obeidat, MD, PhD: Especially with a neuropathic —

Randall Schapiro, MD, FAAN: And alcohol, and things of that nature—you have to watch for that too because that plays a role as well, and that can also make the brain atrophy too, so—

Ahmed Obeidat, MD, PhD: And this is again back to the point where, look at the person and look at everything around that.

Randall Schapiro, MD, FAAN: And … need to say, marijuana does the same thing to the brain. It causes atrophy and cognitive problems if taken too much and at too high a dose. Great for spasticity, great for pain, but maybe not so great for cognitive issues.

Jeffrey Wilken, PhD: There’s such confusion about that in the field right now. People like to separate marijuana from alcohol and what they don’t realize is you’re still affecting … mental status.

Randall Schapiro, MD, FAAN: There’s clear data that it causes atrophy if taken in too high a dose.

Ahmed Obeidat, MD, PhD: These are aspects that sometimes we don’t even ask about, right? And then, the clinic says that you need good practice to be asking about all this.

Jeffrey Wilken, PhD: It’s again a waiting issue. If that marijuana is helping the person so that they’re not in such pain anymore, question is, I guess, for the neurologist, how much is OK and how much won’t affect the brain in other ways, but it’s hard to say, “Just stop it”, right?

Ahmed Obeidat, MD, PhD: Exactly. Well, I thank you both, this a great and rich discussion today, and I learned a lot, and I’m sure our audience learned a lot also. Really, it’s great to see lots of perspectives and also to see how has MS changed from the past, present, and what is the prospect of the future. And to your point, both of you, it’s a bright future. And I think this is really great and it’s uplifting for our audience, and for us, and for everyone. Thus, thank you again and thank you for all our audience for viewing this rich and informative discussion, and thank you to our viewing audience.

Transcript Edited for Clarity

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