Importance of Early Intervention in 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

Fred D. Lublin, MD, FAAN, FANA: Pat, the role of early diagnosis. How important is it?

Patricia K. Coyle, MD: I think the data does support that there’s a window of opportunity in organ-specific immune-mediated diseases. Virtually every single study has said that if you look at early treatment—as opposed to delayed treatment—and you look at late consequences, the early-treated groups are doing better.

And if you believe an immune-mediated attack on an organ like the central nervous system becomes self-perpetuating or self-driven to a certain extent—and that a disease like MS involves accumulating permanent injury—the sooner you intervene, the better.

We can learn lessons from our rheumatology colleagues in rheumatoid arthritis, lupus, and psoriasis, where they really have data that early treatment is critically important. When I think about early treatment for MS, it’s within 3 months of clinically isolated syndrome to have our patient on a disease modifying therapy and an appropriate option.

I think in a paradigm of accumulating permanent injury that is the best possibility of truly changing the natural history of the disease—to stop that damaged paradigm as much as you can in its tracks, early.

Fred D. Lublin, MD, FAAN, FANA: Thoughts? A dozen years ago, this was a big argument, whether you treat CIS (clinically isolated syndrome), or not, or wait until they have a second event.

Clyde E. Markowitz, MD: I personally am in a very similar place to Pat these days in terms of getting people started on therapy as early as I feel comfortable that I have a diagnosis. I don’t even necessarily require all of the pieces of our current diagnostic criteria to start somebody on therapy. If I feel like it really looks like MS after one clinical event, and the scans look pretty good, I will go down that pathway.

Fred D. Lublin, MD, FAAN, FANA: Or the data are fairly compelling, right? We had 6 studies?

Treating people with the first attack who have 2 or more typical looking lesions in the brain, right? We have it for the interferons, we have it for glatiramer acetate, and we have it for teriflunomide, right?

Claire S. Riley, MD: I feel like this is a situation where good communication between patient and doctor is so important. You want to be clear that this is a first attack of multiple sclerosis.

Sometimes, this clinically isolated syndrome verbiage, I think, can be very confusing for people. You want to talk about the benefits of early diagnosis that have been demonstrated. We’ve seen this in several studies that were well conducted. I often discuss the Glatiramer Trial that was stopped early because it was clear that patients who were randomized to treatment were doing better.

But also make sure that the patient is comfortable so that you can maximize the likelihood of adherence and long-term commitment to therapy. I think if it takes another few weeks to be sure that the patient is on board, it’s worth it. Because however much medication they have sitting in their cabinet or in their refrigerator, if they’re not taking it because they don’t believe in the diagnosis, it’s not going to help their MS, right?

Patricia K. Coyle, MD: Well, you’re really emphasizing the importance of sheer decision making, and that the physician partner with the patient so that they truly understand the disease process and the benefits of treatment. I totally agree with that. But really, the treatments are empowering for an MS patient. It allows them to take control of their disease, which is otherwise completely unpredictable and variable.