Future of MS Management


Kristen Krysko, MD, and Robert Fox, MD, look to the future of multiple sclerosis management. 

Bruce Cree, MD: In our last section for discussion, I want to turn our attention to looking ahead and what we think the future is going to look like for managing MS [multiple sclerosis]. I’m going to ask Kristen and Bob to comment on this. Where do we go from here? What do we do next?

Kristen Krysko, MD: We focus on progressive MS, which we’ve been talking about. As we highlighted, we need to focus on having better ways to identify progressive MS, to diagnose it early at a time where they may be more treatable, ways to monitor and capture progression, not only for clinical practice, but also to study medications and their effect on progression. We need to look at developing better tools, be they MRI measures, biosensors, laboratory measures, that can help us monitor and diagnose progression. There’s a lot of work going on in this area. In the future, we’ll have better ways to monitor that. 

As we’ve talked about, we have medications that target inflammation very well and seem to target the active part of progression if someone’s also having relapses or inflammatory activity. Developing strategies to target that progressive aspect of the disease and having a way to get that into the clinic would be a big step in the right direction.

We also need to improve access to multidisciplinary care. A lot of these symptoms we’ve talked about—the fatigue, exercise, nutrition—can all be helped by having a multidisciplinary team in the MS clinics where patients can meet with all many different health care disciplines to optimize their function, even if we’re not able to stop or slow the progression as much as we would like. 

Bruce Cree, MD: Bob?

Robert Fox, MD: I agree. Progressive MS is the big nut that is waiting to be cracked, to figure that out. A key aspect of progressive MS that is an unmet need is: What is it? What is the pathophysiology of progressive MS? What is driving that slow, insidious decline? If we knew that, we could better direct and design treatment trials to test new therapies.

We also need to better understand the 2 ends of the relapsing MS management spectrum. Early on, what is the ideal treatment? Are there biomarkers that can point us to which therapy patients will respond to better? There’s that age-old question: Do we start low and gradually escalate, or do we start with very aggressive therapy? There are 2 ongoing trials that are looking to address that. It’s an important question. Do we come out of the gate guns blazing with a highly effective therapy, or do we escalate? Is that an acceptable approach?

At the other end of the relapsing spectrum are the older patients who probably don’t need MS therapy. Can we stop the therapies? How do we stop them? What are the risks and benefits of stopping them? There are a couple of ongoing trials, from which we should get answers over the next few years. It’s an important question. We have our patient doing well, but does the patient still need therapy now that they’re 20 or 30 years into their MS?

Bruce Cree, MD: Discontinuation of treatment is a very interesting and highly controversial topic that we’re going to have to wrestle with more and more as our patients age out of the inflammatory phase of the disease.

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Transcript Edited for Clarity

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