Physician Roll Call: Unmet Needs in Multiple Sclerosis

Multiple sclerosis (MS), the complex neurodegenerative disease that was the focus of MS Paris 2017, the 7th annual joint meeting of the European and American Committees for Treatment and Research in Multiple Sclerosis, is as complicated to treat as it is to understand. Although current treatments are capable of handling the early inflammatory stages of the disease, there remain many unmet needs in the space.

Several experts in MS treatment sat down with MD Magazine to discuss those unmet needs, and what needs to be done to move the advancement of treatment along. While each of them had a different answer, all stressed the need to quickly and effectively produce clinical results for this debilitating condition.

Martin Weber, MD, of the University of Göttingen:

The biggest unmet need, clearly, is drugs that are acting on the central nervous system itself. I think we became very efficient in treating the immune system and preventing relapses, and preventing lesion formation.

I think that's that's a really achieved goal, so to say, but I think the continuous process in the CNS, both inflammation, and degeneration, is only partly dependent on this de novo infiltration, and that is a process we are we are only starting to understand, which is probably really relevant for disability, for atrophy - so for the hard clinical outcomes, so to say, in patients. These probably can only be influenced by identifying and targeting crucial steps within the central nervous system, probably involving microglia, astrocytes, etc., so new players of CNS resident cells where there is basically no evidence that any of the established MS drugs are affecting these cells at all.

Ruth Ann Marrie, MD, PhD, FRCP, of the University of Manitoba:

It's hard for me to identify just one, I mean I think, one of my interests is in comorbidities, that it gives us a more patient-centered approach. So we're not just focused on fixing the MS, but we're saying we have a person with multiple sclerosis who also carries with them an entire life history and other conditions. We need to find a way to really be able to tailor our care both to that individual’s goals and needs, as well as to the specific aspects of that person so that we can really come up with a regimen unique to that person that will really give us the best possible chances of improving their quality of life.

Aaron Boster, MD, of Ohio Health:

I think the biggest unmet need is overcoming something called therapeutic inertia. In our field therapeutic inertia is ripe, and what I mean by that is you identify that someone's not doing well and you don't change what you're doing to take care of them. This is a concept that was originally born the hypertensive literature - you got high blood pressure, you started medicine, at follow-up you still have high blood pressure, nothing changes.

Here, the stakes are much higher, and I think that for multitudes of reasons patients, clinicians, even third-party payers, are complicit in allowing a patient to languish. It's even worse in that the effects that we apply, drugs that we apply today, we're looking for downstream benefits 15 years from now. So if you're not attentive, you don't see change too quickly. I think that the biggest unmet need is addressing the critical importance of timely diagnosis and timely escalation of therapy when appropriate. We're missing that piece, and it's my hope that as we move forward as a group of treaters that we overcome that.

John Corboy, MD, of the University of Colorado:

All the therapies that are presently available are really anti-inflammatories of one form another. They all modulate, suppress, alter, or change the immune system in way shape or form. But there's a whole neurodegenerative component that's out there, and focusing on neuroprotection, focusing on remyelination, focusing on repairing and replacing damaged nerves and the brain and the spine and optic nerve - to me, that's that's the next step.

We have to get to there because there's an incredibly large unmet need for a lot of people with disability who either never got access to the medications we've been talking about, or they, for whatever reason, didn't do well with them. So to me, the biggest unmet need is progressive MS, and altering our view trying to move not away from, but in addition, to immunotherapies to the addition of those things that will protect and/or salvage the nervous system.

Francisco Quintana, MD, of Brigham and Women's Hospital:

So, hand-in-hand with having therapies for progressive MS, what we need is reliable biomarkers that any neurologist in his or her practice can use, in order to monitor disease progression and response to therapy. We're actually going to need that when we come up with trials to test these new kinds of drugs because, as you know, it's very difficult to run a trial with progressive MS, so the more data we collect from those trials, and the more sensitive a signal we can get from those trials, the better they will be. So our unmet clinical needs are precise therapies for progressive MS and, I would say, reliable biomarkers.