Strategies in the Management of Relapsing-Remitting Multiple - Episode 6

Multiple Sclerosis: Goals of Initial Therapy

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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, let’s start with goals of first-line therapy and again, the issue of early intervention.

Patricia K. Coyle, MD: You need an effective disease-modifying therapy that’s going to minimize breakthrough disease activity—clinical and on the MRI scan. I think, by consensus recently suggested, we’re doing a new baseline brain MRI with or without contrast 6 months after we start a new treatment, and then may go to every year or so.

You also need a disease-modifying therapy that’s going to be tolerated by the patient, and this is where the shared decision making becomes very important. So, you have a discussion because you need to come up from the get-go. You don’t want to set yourself up for failure. You want to choose what you feel is the optimal disease-modifying therapy that’s going to be a good experience for the patient, from the beginning, to control their disease.

So, my goal is minimal to no breakthrough disease activity in a very tolerated therapeutic regimen, where the patient’s self-report is saying, “I’m really doing very well, I feel very well.” I want them to have a normal life. That’s what I want to be able to tell them—“If you work with me, if you stay on treatment, you’re going to have a normal life.”

Claire S. Riley, MD: I take a very similar approach. We want to control the disease activity as completely as possible, and also with a risk-benefit ratio that’s acceptable to the patient. Everybody’s different in terms of how they interpret risk. It’s been sort of a sociologic lesson that I’ve found in my practice. I can’t always predict how people are going to respond to risk parameters. They’re not necessarily the same as what I think. But, I present the information on what I think the optimal therapy would be and then we make that decision together.

Fred D. Lublin, MD, FAAN, FANA: So, efficacy, safety, tolerability, and I throw in the hassle factor.

Patricia K. Coyle, MD: Hassle for whom?

Clyde E. Markowitz, MD: All parties.

Fred D. Lublin, MD, FAAN, FANA: Everyone. So, who else is in the room with you, besides you and the patient, when making decisions for that patient?

Clyde E. Markowitz, MD: Right.

Fred D. Lublin, MD, FAAN, FANA: In terms of their insurance, and the things that they limit them to, and rules—we have it in this country—with insurance carriers making arbitrary decisions. In other countries, where the healthcare resources are more centrally controlled, they’re making the arbitrary decisions as to availability. In an ideal world, those are the things that we’ll have to look at. But I think that you alluded to this, that the drugs are not going to do the patient any good if they don’t take it.

Patricia K. Coyle, MD: Absolutely.

Fred D. Lublin, MD, FAAN, FANA: So, they have to be a partner with this. That’s why this is a very long conversation. Someone will call me and say, “Well, give me 5 minutes on how to decide to put someone on therapy.” And I say, “Well, no. It’s an hour conversation.” Then, of course, you go through all these various permutations and everybody looks at this somewhat differently.