The Future of Multiple Sclerosis Management

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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: What about biotin?

Patricia K. Coyle, MD: Very interesting. This is vitamin H. We think of biotin for hair and nails, but it also has actions where, in theory, it could increase the fuel supply (adenosine triphosphate supply) for stressed axons, and might actually boost remyelination.

There was this intriguing study—they called it a phase III, but it only had about 150 progressive MS patients from France. They entered primary and secondary progressive MS patients, but they looked, actually, at improvement in fixed deficit. Patients were randomized to 300 mg, which is an enormous amount of biotin, versus placebo. At the end of a year, 0% of the placebo arm were improved on their exam, where confirmed improvement was measured on the Expanded Disability Status Scale. Thirteen percent of the high-dose biotin had actually improved. Now, they’ve had a subsequent chronic optic neuritis vision loss trial that failed, but they are continuing to study it. This is kind of amazing. I think it’s well worth looking at further.

Fred D. Lublin, MD, FAAN, FANA: We’ve just reviewed and discussed a lot of information related to the strategies that are being used in the management of MS, specifically in relapsing-remitting disease. Before we conclude the discussion, I’d like to ask each of our panelists for any final thoughts, and we’ll start with Dr. Coyle.

Patricia K. Coyle, MD: I’m going to emphasize the wellness, health maintenance, vascular risk factor program. This needs to be touted to every single MS patient at the time we are initially diagnosing and making treatment decisions—really to emphasize how valuable that is to help preserve and boost their central nervous system reserve.

Fred D. Lublin, MD, FAAN, FANA: Good. Dr. Markowitz?

Clyde E. Markowitz, MD: I think about how we’ve evolved over the last two decades with medications and the fact that we now have 13 compounds—soon to be maybe 14 or 15 compounds in the near future—and we really have the ability to address and stop the inflammatory activity in MS. I think the next phase of our discovery will be looking at how we address the neurodegenerative phase, and then if we can ultimately repair the damage that’s there. But there has been tremendous progress in the field. I’m very excited for the future of what we’ve got to look forward to.

Fred D. Lublin, MD, FAAN, FANA: Dr. Riley?

Claire S. Riley, MD: From a practical perspective for the treating neurologist, I think this proliferation of therapies can be a little bit overwhelming. I think that the key feature, to me, is really being able to partner with our patients to make a plan for choosing the right immunotherapy, deciding what our benchmarks will be along the way to assess for response, and really getting that buy-in for monitoring and safety—as we use these therapies over the long-run. I think that’s the key.

Fred D. Lublin, MD, FAAN, FANA: So, the neurotherapeutic approach to multiple sclerosis has been an incredible journey. Now, we see the door opening for progressive disease, and also for repair. That’s very exciting. Things are moving forward.

This has been a great discussion. We thank you for joining us for the MD Magazine Peer Exchange, and hope you found the program to be informative. Thank you, all, for joining us.