Q&A: Fred Lublin, MD, on New MS Treatment, Combination Therapy, and Nervous System Repair

Fred Lublin, MD, has been a prominent figure in multiple sclerosis (MS) treatment and research for decades. The neurology professor at Mount Sinai Hospital and executive committee member of the International Medical & Scientific Board of the Multiple Sclerosis International Federation has been involved in many major clinical trials for MS care. At the 2017 Consortium of Multiple Sclerosis Centers in New Orleans, he shared his thoughts on the current state of diagnosing, researching and treating the neurological disease.

The biggest trend we’ve seen in conversation at the conference has been these burgeoning drugs that have been approved as recently as this year, which have been prominent in alleviating RRMS and all the other doors they could open to. Can you elaborate on what this means for the state of MS treatment?

So, we now have 15 approved agents, all of them approved for relapsing forms of MS (RRMS), and one approved for primary progressive MS (PPMS). This marks 24 years now that we’ve had treatments, which is a remarkable thing for any neurological disease — especially multiple sclerosis.

It’s even more remarkable when one realizes we’ve been so successful in treating relapsing disease, and still don’t know the cause of MS. The other very exciting aspect of what’s happened this year is approval of an agent for treating progressive disease (ocrelizumab). It’s a modest effect, but we’ve never had an agent before that gave us unequivocal evidence of treatment, potential for progressive MS.

The challenge is going to be to parse through who are the best progressive MS candidates to receive the therapy.

With these new drugs, is there any hope for new forms of combination therapy?

Combination therapy, we tried in a study called the CombiRx trial that I ran with my associates, which showed that a combination of anti-inflammatories didn’t give enough of a benefit. In the future, what we’d like to see is the combination of an anti-inflammatory agent and a newer protective, or a repair molecule. That would be a good combination.

Combinations of the anti-inflammatories themselves is possible — it’s a little challenged by the fact that there’s an enormous cost of current drug prices.

If you could project a next step to be taken in overall treatment of MS, what do you think it would be?

Next big steps in treatment will be in better approaches to progressive disease, both primary progressive and secondary progressive, beyond the modest effects we’re seeing now.

And, molecules or approaches for repair to the damaged nervous system. We have some early studies which are interesting — not there yet, but repair is really on the horizon. It’s a terrific goal for us.

In terms of diagnosing, a few doctors have expressed concern with some doctors being too conservative in dictating MS in a patient, as opposed to another neurological disease. Is there any tangible way that can be alleviated, or is it just a mindset?

Well, we have diagnostic criteria, and we’ve revised them. So new diagnostic criteria will be published later this year, which are a refinement on our current 2010 international panel criteria.

There’s always an issue with over-diagnosis, under-diagnosis. The best way to deal with that is with education.