Characterizing Multiple Sclerosis

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The MD Magazine Peer Exchange “Strategies in the Management of Relapsing-Remitting Multiple Sclerosis” features a panel of physician experts discussing the importance of early therapy in multiple sclerosis treatment, factors that affect choice of management strategy, the need for ongoing monitoring, and other aspects of treating patients with multiple sclerosis.

This Peer Exchange is moderated by Fred D. Lublin, MD, FAAN, FANA, Saunders Family Professor of Neurology and director of the Corinne Goldsmith Dickinson Center for Multiple Sclerosis at Icahn School of Medicine at Mount Sinai, New York.

The panelists are:

• Patricia K. Coyle, MD, professor and vice chair (Clinical Affairs) and director of the Multiple Sclerosis Comprehensive Care Center at Stony Brook University Medical Center, New York
• Clyde E. Markowitz, MD, associate professor of neurology and director of the Multiple Sclerosis Comprehensive Care Center at Perelman School of Medicine, University of Pennsylvania, Philadelphia,
• Claire S. Riley, MD, assistant professor of neurology and director of the Columbia University Multiple Sclerosis Clinical Care and Research Center, Department of Neurology, Columbia University, New York

The segment opens with a discussion on the different types and courses of multiple sclerosis, and how they’re diagnosed and characterized. Dr. Riley notes that relapsing-remitting multiple sclerosis (MS) is the most common subtype, and that it is characterized by episodes of neurologic dysfunction that “come and go.” Patients may not completely recover from a relapse, but they are stable between attacks.

“Over time, that form of multiple sclerosis, which is the initial presenting course, 85% or 90% of people can change into a secondary, progressive form of MS where I would say relapses, though not impossible, become less prevalent and probably less important. People will have gradual worsening of neurologic function,” Riley says.

The other 10% or 15% of people experience primary progressive course without true relapses and gradual worsening of neurologic function. According to Riley, “That is the subtype of MS that we’ve had more difficulty in finding treatments for and are only now starting to sort of glimpse at the possibilities of effective treatments for primary progressive MS.”

Asked about subcategorizing patients as active or not active, Dr. Markowitz notes, “We all see patients who have disease activity, either clinically or radiologically by MRI scans, and their clinical course may not end up changing. Maybe they have a slow, progressive course that can be secondary or primary progressive, but you see them to be active with scans that show active lesions.”

He says the new MS classification gives providers the ability to subcategorize people into active MS (whether they have a relapse or new MRI activity) or inactive.

When you consider the population of patients with progressive MS, which Markowitz says is particularly important based on some of the recent study data, “you can actually have a drug that affects this progressive phase of the disease, provided that they show evidence of activity, either clinically or radiologically. I think that there’s a helpful distinction there to be able to use those kind of subcategories,” he says.

Dr. Lublin notes that new data suggests “relapses are important, not only for what they predict in terms of progression of disease, but also what they may predict for response to therapies later in progressive disease.”

Dr. Coyle says that in addition to relapsing MS, there is also primary progressive MS and secondary progressive MS (wherein a relapsing patient then moves into a gradually worsening phase). She says that clinically isolated syndrome (CIS) is also an MS phenotype.

She also adds radiologically isolated syndrome (RIS), which is when “a patient who has no neurological history and has a brain MRI that appears to be very abnormal and looks like MS, but has absolutely no history of any issue. And a proportion of them appear to have silent MS and go on to present as either relapsing or primary progressive MS in the next couple of years. It’s kind of an interesting phenotype.”

Lublin says that there will be a revision of the McDonald criteria for 2017, which he expects “will take up whether it’s reasonable to have a pure MRI definition of multiple sclerosis.”