Optimal Management of Relapsing Multiple Sclerosis: Advanced Practice Providers Perspectives - Episode 2
Important insight related to individualized treatment approaches for patients with relapsing multiple sclerosis.
Amy Perrin Ross, APN, MSN, CNRN, MSCN: What are your strategies for treating relapsing MS [multiple sclerosis], and how do you decide on a therapy for relapsing MS? And I’ll ask Stephanie to take the lead on this one.
Stephanie Agrella, PhD, APN-BC: That’s really a great question, Amy. And one thing we can all agree on is that there isn’t a simple answer. In MS, we just don’t have an algorithm for treating it. And that’s certainly something with other kinds of chronic diseases, like hypertension, that is available, and that can be used to guide treatment decisions for those particular patients. But MS is such a heterogeneous disease; each person is so unique. That makes algorithms for us in the fields of MS kind of implausible. It’s an advantage that we have as MS providers though. It really allows us the unique ability to personalize and practice the art of individualized and tailored treatment based on the person or the patient who’s in front of us. With all of that said though, one thing that we can all agree on is that when we’re talking about treating relapsing MS, and this goes back to what Bryan was saying earlier, again, we have the McDonald criteria available to us now; we’re diagnosing people earlier, and that allows us the ability to begin treatments earlier. With that said, I would think that certainly, and I’m not the first person to say this, one of the key strategies when we’re talking about treating people with relapsing MS is that we should begin their treatments early. We have seen study after study demonstrate the advantages of early treatment. In fact, nearly every city that I’ve seen, and I’m sure you as well, we always see that subset of individuals who got earlier treatment, and they fared better later, as opposed to those who maybe did not. A fundamental therapeutic principle is to begin their treatments early.
Then the question is how do we decide on that disease-modifying therapy [DMT]? And again, we just don’t have an algorithm to look toward. And while it’s great to have therapeutic options, at this point, we have 19-plus different disease-modifying therapies to choose from; and options are great, but it can give us some challenges when we try to zero in on the one that’s right for that patient. We’re trying to personalize the treatment. And we take into consideration their disease, their medications, whatever medications they’re on, certain patient factors, comorbidities, or maybe risk tolerance for that patient. And that helps us to guide our decision and our discussion with patients. It helps us to weed out those therapies that maybe aren’t appropriate, or even are contraindicated. Again, just sort of narrowing down our options so that we can come to the right choice. We also of course take into consideration disease severity, the burden of disease, checking their MRIs, looking at their recovery from prior relapses, assessing their disability levels, and looking at all the prognostic factors that help us to make good treatment decisions. And from there, clearly, we have those patients who have mild MS; we have some who are more moderate; and then unfortunately, we have those who have more of an aggressive or severe MS, so we have to make a treatment choice based on that. And I think, obviously, when we have somebody who’s really highly active, we’re going to be much more eager to likely begin and discuss higher efficacy therapies with those; and I think that’s certainly appropriate.
Of course, when we talk about the treatment strategies, we also have to talk though about the concept of induction and escalation. And as you all know, induction therapy, we start with that high efficacy DMT in the very beginning at the time of diagnosis. And that’s, of course, in contrast to escalation therapy, where maybe we start with a lower efficacy therapy, and we change the therapies in a step wise fashion, moving up on that efficacy ladder in response to MS activity. I don’t know that every person with relapsing MS needs to be on the highest efficacy therapy we have. We don’t know enough at this point to know if it’s appropriate to place somebody who has maybe mild MS or more mild MS on those highly efficacious therapies given the potential risk. But as we continue to learn, and as we gather more outcome data from studies, like the TREAT-MS trial and others like it, which are really trying to investigate to see if one group does do better if they are randomized to high efficacy versus using more of an escalation approach, is going to be important for us. It’s going to provide us as MS providers and our patients, frankly, more data so that we can make better and more educated treatment decisions with our patients, which of course in the long run, will really benefit all of us.
Amy Perrin Ross, APN, MSN, CNRN, MSCN: Thank you all so much. I would like to thank this wonderful panel, Christen Kutz, Stephanie Agrella, Bryan Walker, and Patricia Melville, for this wonderful discussion. I’d like to thank you as an audience for watching NeurologyLive® Peer Exchange. If you enjoyed the content, I would suggest that you subscribe to the NeurologyLive® newsletters to receive information about upcoming Peer Exchanges and other content available to you. Thank you all so much.
Transcript edited for clarity.