Experts in neurology discuss the considerations and practicalities of treating patients with multiple sclerosis who may undergo surgery and explore the role of treatment holidays.
Jeffrey Dunn, MD: Medications approved for the treatment of multiple sclerosis [MS] work precisely because they decrease or down regulate the immune system and yet the immune system is essential for being able to fight off infections and malignancy. How do you address the question of a patient who is about to undergo a surgery where they might need an extra level of a healthy immune system to be able to minimize the complications of the surgical procedure and the postoperative course? Do you bring certain considerations to specific therapies, to discontinuing therapies, to reversibility, as we talked about before, or just your general approach that you could share with our colleagues?
Regina Berkovich, MD, PhD: It’s an important topic because we sometimes may be dealing with a patient who already (is) experiencing a problem of urosepsis, for example, so you have to deal with it immediately right now. Then it could be a problem of, as you said, the surgery, and this is one of the reasons I must say why I'm always in favor of reversible medications. Even within the class of immunosuppressive drugs some of them are more reversible and some of them are less reversible. I'm more in the favor of more reversible medications because they give me this agility, this freedom of maneuver.
Jeffrey Dunn, MD: The philosophy here is if a patient is on a medication that has high reversibility or a relatively celeritas or expedient reversibility perhaps that medication could be held for a more limited period of time to allow their immune system to reconstitute to minimize postoperative complications?
Regina Berkovich, MD, PhD: Probably.
Jeffrey Dunn, MD: Are you thinking differently on that?
Regina Berkovich, MD, PhD: No, I'm not contraindicating this. I only would like to say that we have to be keeping a fair balance here in between the reconstitution of (the) immune system that might be indeed necessary for the healing process and at the same time not to allow MS to reactivate. We might be in need of more close monitoring of those patients, and, if the patient is having surgery, then be a bit more connected to the surgical team and maybe breach the treatment with a different medication or be ready to use the acute therapies, if needed. I believe that this is what the art of medicine is. You're ready for different scenarios on a daily basis.
Jeffrey Dunn, MD: It's a challenge for sure; all of our colleagues know that.
Transcript Edited for Clarity