How do you approach the management of patients with multiple sclerosis and another autoimmune condition, such as psoriasis?
Multiple sclerosis is associated with a number of comorbidities, some of which are routinely managed by neurologists, such as headaches and sleep problems. However, neurologists do not typically manage the immunological and rheumatologic comorbidities associated with MS. The treatments of immunologically-mediated conditions may complicate or interfere with the treatment for MS.
Common Immunological Conditions Associated with Multiple Sclerosis
Psoriasis, rheumatoid arthritis, and lupus are some of the immunological conditions that are most often diagnosed in patients with MS. A recent Danish study found that patients with psoriasis have two to three times the incidence of MS when compared to the control population, with a higher association among patients who had worse psoriasis. Similar results link multiple sclerosis with autoimmune diseases such as rheumatoid arthritis and systemic lupus erythematosus.
Management of Multiple Sclerosis Along with Comorbid Conditions
The mainstay of disease control in MS lies in immunosuppressive treatments, particularly interferons, oral prednisone, and IV steroids. Other immunosuppressive agents are used as well.
Psoriasis is often managed with topical treatments applied to the affected areas of skin. Severe cases are treated with systemic immunosuppressants, most of which are not standard treatment for MS, but which might have an effect on short-term or long-term MS disease activity. Lupus and rheumatoid arthritis, likewise, are typically managed with a regimen that includes steroids and other powerful immunosuppressive agents.
Generally, immunosuppression is believed to control symptoms of MS and to ameliorate the long-term burden of disease, but there have not been studies measuring the effects of the use of shared immunosuppressive treatments for MS with another immunological conditions at the same time. Issues such as the decision to initiate therapy, to treat with pulse therapy vs. long-term maintenance, to adapt therapy in response to imaging results, blood tests, or clinical symptoms can make co-management tricky. The obvious risk of infection is also a risk that should not be underestimated, as it affects a patient’s overall health, as well as having the potential to exacerbate symptoms of underlying disease.
When you take care of a patient who has multiple sclerosis and another autoimmune condition such as psoriasis, do you typically approach the management of the concurrent disorders, both of which have an immunologic component, independently of each other or in coordination with each other? Given how complex the consequences of immunosuppressive agents are, do you coordinate management of patients who have both MS and psoriasis with a dermatologist or with an immunologist? Would you readjust your treatment for MS based on the systemic treatment given for rheumatoid arthritis, psoriasis, or systemic lupus erythematosus or would you prefer that the systemic treatment be adapted to suit the treatment regimen for MS?
Egeberg A, et al. Risk of multiple sclerosis in patients with psoriasis: a Danish nationwide cohort study. J Invest Dermatol. 2016 Jan;136(1):93-98.
Marrie RA, et al. A systematic review of the incidence and prevalence of comorbidity in multiple sclerosis: overview. Mult Scler. 2015 Mar; 21(3):263-281.