RRMS Treatment Initiation and Management


Heidi Crayton, MD, shares her thoughts surrounding treatment initiation and management considerations in patients with relapsing-remitting multiple sclerosis.

Heidi Crayton, MD: It's generally thought that as soon as somebody receives the diagnosis of relapsing-remitting multiple sclerosis, that we should initiate treatment. I do things a little differently because I think that you need to give people time to digest all of that. Everything is kind of shut out; they tune out after they hear MS [multiple sclerosis]. Most of the educating that you do after that sound bite sometimes goes in 1 ear and out the other. I like to have people go through the educational process. I tell them about MS, explain it, and then have them come back and talk about a treatment option. I usually have favorite things that I direct people towards depending on their presentation of MS. I like to give people choices, but I usually do not give them a choice of 1 out of 24 options. People that are automatically in a higher-efficacy–required category for me include people of color. There are a lot of ethnic differences with MS-like autoimmune conditions, MS in African American patients is by far the most involved and deserves to be treated with high efficacy therapy at onset. The same applies to patients who are Hispanic, of Middle Eastern heritage, and men. Typically, men have more involvement with their multiple sclerosis than women do. With MS, it's all about location. I say to patients, people can have 100 spots in their brain and have no idea they have a problem. It's like if a car breaks down on a 6-lane highway: other cars can go around it, but if a car breaks down in a tunnel, we get backed up; that's how our nervous system is. My treatment goal is always to try as much as I can to not let people know they have MS. Our job is to treat to the highest efficacy that that person's MS requires.

The therapeutic landscape for MS has exploded. I've been in MS for 20 years, and we've had this explosion of therapies and options, but that doesn't mean that they're all appropriate for everybody. I don't think about initiating therapy with the initial products that came to market—the self-injected interferons or… acetate. I think that we've moved beyond that. I know that there is some disagreement around that concept, but I think it's hazing. If I was diagnosed, especially as a young person, I would be very overwhelmed by having to give myself an injection of something that gave me adverse events on top of that. It was a hard sell for people who often weren't very compliant, because the adverse events of the medication were worse than their MS symptoms. I talk to people, about what options they have, oral therapies, IV therapies. There is a high-efficacy injected product, and it’s on the market. It's important that people understand the mechanism of action, because if they understand the mechanism, they understand the adverse event profile and why we're monitoring for the things that we watch for with various products. I like to give a quick sentence, just so that people understand. I talk about lymphocytes and how we have these 2 different kinds of lymphocytes that are misbehaving—that are doing the job they're supposed to do, but doing it in the wrong place. We have different therapeutic options. We have some that tuck cells away—kind of put them in time out and don't let them out to misbehave. We have a product that is a security guard at the gate—the gate being the blood-brain barrier, and it doesn’t let them in; doesn’t let them over the border. We have products that ablate, that wipe out the bullies so they can't get the other cells revved up, and we have reboot mechanisms. It's important that people understand these simplistic explanations, so that they understand why we see the adverse events that we do and what we're monitoring when on those medications. Let me talk about how they're metabolized: if they go through the liver, like most of our products do, I monitor that with simple blood tests. It’s important for people to understand a little bit about the drugs and how they work so that they feel a bit more empowered—that it's not just something that's being done to them.

Transcript Edited for Clarity

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