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Cognitive Health and Sphinogine-1-Phospate Receptor Modulators in Multiple Sclerosis - Episode 1

Overview of Multiple Sclerosis

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Heidi Crayton, MD; Jacqueline Nicholas, MD; and Flavia Nelson, MD, provide an overview of multiple sclerosis shedding light on the clinical course of disease.

Stephen Krieger, MD: Hello, and welcome to this Neurology Live® Peer Exchange titled "Cognitive Health and Sphinogine-1-Phosphate Receptor Modulators in Multiple Sclerosis." I'm Dr Stephen Krieger from the Icahn School of Medicine at Mount Sinai in New York City, New York. Joining me today in this discussion are 3 of my colleagues: Dr Heidi Crayton from the Multiple Sclerosis Center of Greater Washington, Vienna, Virginia; Dr Jaqueline Nicholas from the OhioHealth Multiple Sclerosis Clinic at the OhioHealth Riverside Methodist Hospital in Columbus, Ohio; and Dr Flavia Nelson is a professor of neurology at the University of Miami in Miami, Florida.

Our conversation today will focus on changes in cognitive health during the course of multiple sclerosis [MS], what we know about brain volume loss, and strategies to prevent cognitive decline. We'll also share data with S1P [sphingosine-1-phosphate] receptor modulators and other disease-modifying therapies and the role they may play in preserving cognitive health. Welcome, everyone. Let's get started. Dr Crayton, I'll start with you. Let's talk a little bit about multiple sclerosis and an overview of the clinical course before we get into cognitive health specifically.

Heidi Crayton, MD: I think that the clinical course of MS has actually changed over the decades that I've been involved in the MS space. It used to be doom and gloom, and by the time people were diagnosed, they were shortly facing physical disability and decline. And I think that that has changed because we diagnose so much earlier, and we really focus now on preservation much more than we used to. When I first see a newbie, I ask if they know anybody who has MS because I need to understand whether or not I need to have them erase a picture and start from scratch or whether we really are starting from scratch—because the face of diagnosis really has changed a lot because the face of MS has really changed a lot. We know that there are some physical changes that can happen, but I think that our attention has really turned more towards cognitive decline and loss of CNS [central nervous system] tissue.

Stephen Krieger, MD: Dr Nicholas, would you agree? Do you think cognitive function is something you're talking to patients about early and assessing early in the disease course?

Jacqueline Nicholas, MD: Yes, and I really am. And unfortunately, I think this is talked about more and more. When I first started in MS, there were a lot of people out there that said that cognitive dysfunction was not an issue in MS. But I think we all know that this couldn't be further from the truth. And I often find that even patients who are coming in at the time of their first attack are telling me, “I feel like I've been having some challenges with finding my words.” And thus, I think if you ask about it, you'll find it's there.

Stephen Krieger, MD: Yes, I think that's true. And Dr Nelson, to think about in your practice, what proportion of patients do you think have cognitive symptoms early? And what proportion of patients do you think develop cognitive symptoms of MS?

Flavia Nelson, MD: Well, we know that as a disease progresses, cognitive impairment is more prevalent. It's definitely going to be the patients that have longer disease duration or perhaps are in secondary progressive MS. And studies have shown that is definitely more prevalent in progressive disease—not only secondary progressive but primary progressive. I think I couldn't tell you a percentage; it depends on your patient population.

Stephen Krieger, MD: Sure.

Flavia Nelson, MD: But I have a large population of secondary progressive MS. And not only their age— fifties, sixties—but the disease duration also plays a role in cognition issues.

Stephen Krieger, MD: I think you're right. And to me, one of the challenges in how we describe MS is if we consider relapsing/remitting MS a form of the disease where there hasn't been disability that has crept in gradually, but just from relapses. Most cognitive dysfunction doesn't fall into that category. It's more gradual. I think even the way we define the disease, cognitive dysfunction, cognitive disability is often a sign of progression, either primary progression or secondary progressive disease.

Flavia Nelson, MD: Absolutely. Unfortunately, there are patients that present with cognitive impairment at diagnosis or at the onset of the disease, and it's like my colleagues mentioned. We've made a lot of progress in terms of being able to be aware that this could be an issue and detected early.

Transcript Edited for Clarity