Talking to Patients about Their Multiple Sclerosis

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The MD Magazine Peer Exchange "Modifying the Course of Multiple Sclerosis in New Ways: The Latest Advances in Treatment" features a distinguished panel of physician experts discussing key topics in multiple sclerosis (MS) research and management, including the latest insights into MS pathophysiology, new medication options and their application in clinical practice, and more.

This Peer Exchange is moderated by Paul Doghramji, MD, who is a family physician at Pottstown Memorial Medical Center in Pottstown, PA, and medical director of Health Services at Ursinus College, in Collegeville, PA.

The panelists are:

• Fred D. Lublin, MD, FAAN, FANA, the Saunders Family Professor of Neurology and director of The Corinne Goldsmith Dickinson Center for Multiple Sclerosis, and co-chief editor of Multiple Sclerosis and Related Disorders at the Icahn School of Medicine at Mount Sinai
• Patricia K. Coyle, MD, professor of neurology, vice chair of Clinical Affairs, and director of MS Comprehensive Care Center
• Suhayl Dhib-Jalbut, MD, professor and chief of the Department of Neurology at Rutgers, Robert Wood Johnson Medical School

A patient’s first visit for MS is typically lengthy and difficult. Coyle said, “It’s very helpful to have family, significant others there because sometimes it goes in one ear and out the other. You’re in a panic when you are diagnosed. You have no idea what MS is. You may have the concept of a wheelchair, I’m going to be crippled. It’s a horrible thing.” Lublin agreed and added, “We’ll sometimes separate out the diagnostic visit from the treatment visit because it’s just too much to handle in one.” If family members are in the room, he suggested looking around to determine who heard and who did not. The person who heard is “the person you have to make sure understands everything because the others are going to walk out and say, ‘I’m not sure I understood what he said.’”

To help patients and families understand, Dhib-Jalbut gives out two sets of material comparing aspects of different treatments after settling on one or two treatment options. The treatment decision is then made after they have had a chance to digest the material.

There is no clear definition of treatment failure, said Lublin, and “the only way to know of course is to switch and go to other things.” It is hard to determine if it is treatment failure or simply disease progression. Coyle said that she would consider switching treatments in that case. “I do believe there’s a window of opportunity to get an optimum response to a disease-modifying therapy,” she said, but “There are different ways to fail.” These ways can include intolerability, noncompliance, or unacceptable breakthrough activity.

In the absence of absolute treatment guidelines, Coyle said, “I think we can start to say treat early, use the prognostic profile and disease activity, follow them closely. If there’s unacceptable activity, make a switch. I mean, these are central principles I think everybody could endorse right now for MS.”