Patricia Coyle, on Advancing Multiple Sclerosis Treatment and Outcomes Podcast

In this podcast Q&A, Dr Coyle answers questions about the presentation, treatment, and diagnosis of multiple sclerosis (MS).

Patricia K. Coyle, MD, is a director of the MS Comprehensive Care Center, and professor of neurology, at the Stony Brook Neurosciences Institute.

Transcript:

Dr. Patricia Coyle: My name is Dr. Patricia K. Coyle. I'm a professor of neurology and I direct Stony Brook's Multiple Sclerosis MS Comprehensive Care Center. I'm delighted to be with you today.

At a recent meeting, I presented advancing multiple sclerosis treatment and outcomes, which was really an outline of what we know about MS currently, what we understand about the immune-mediated nature of MS, our current therapies, particularly disease-modifying therapies.

MS has been a great success story in developing DMTs that decrease damage from the disorder to the central nervous system. Then a look at the future. What are future therapies? What are our needs? What are cutting-edge developments in getting better handles on looking at the neurodegenerative component of MS, in particular, and following patients?

I was given several questions to answer. The first is, what do I see as the greatest challenges in treating and diagnosing MS? Everything starts with an accurate early diagnosis. That's key, and there is a misdiagnosis rate. People are told they have MS and they do not have it.

Now, I really think it's key to use the formal diagnostic criteria for MS. These are the 2017 revised McDonald MS diagnostic criteria. Anybody currently making a diagnosis of MS should be able to say whether the patient meets those criteria or not.

It's very important to be thorough in the workup. Although we say MS is a clinical diagnosis, it's key to do appropriate laboratory workup. That would be selected blood tests, MRI imaging of the central nervous system to include the brain and the spinal cord down to the cornice, cervical, thoracic, and the cornice.

We look at cerebrospinal fluid, CSF, in every patient that we're making a diagnosis of MS on. If you do that thorough workup, then you can really minimize misdiagnosis, and everything starts from making an accurate diagnosis.

Other greatest challenges, as choosing the best disease-modifying therapy. Counting generics, we have more than 25 DMTs for MS covering 10 distinct mechanisms of action. Also, as we start a disease-modifying therapy and follow our patients, when do we switch? When is the proper time to switch? These are real challenges at the current time.

I'm asked what are some of the most common questions that I get during the treatment process with my MS patients? One basic question is, what does a DMT do? I describe it as an invisible therapy because I need an intellectual buy-in from the patient.

It's not designed to have somebody feel better. It's not designed to make them better. It's not designed to treat symptoms. Rather, it's designed to minimize new events that have not occurred yet. That new or next relapse, that silent lesion on the MRI scale, development of worsening on the neurological exam. That's a very common and very important thing to explore.

Patients are asking us, as the experts, what's the best disease-modifying therapy to go on with multiple options? Shared decision-making is a key point. I can certainly assess the MS component of it. Do they seem to have bad disease? Are they fitting into a poor prognostic profile?

I'm very familiar with the disease-modifying therapies and pros and cons, and how they're given, and the monitoring, and their degree of efficacy, but you need to know something about the patient as well. What is their risk tolerance? What is their lifestyle? What is their expectation?

Looking at patient, drug, disease factors, as well as practical factors, what's going to be available from third-party payers, can all help to come up with the best option. Another common question, since the prototypic MS patient is a young woman of childbearing age, how is MS going to affect my ability to get pregnant? Will it affect my child? Can I be on a disease-modifying therapy?

Family planning is a key component in MS. Very important to be knowledgeable about that, and health care provider needs to be able to speak with real expertise and knowledge in making recommendations to the MS individual.

Another question I was asked, will patients with MS, who are currently asymptomatic, inevitably develop symptoms and see disease progression? I would say the following: a principal hallmark of MS is variability. No two patients are alike. In fact, MS can be silent.

Autopsy studies, if you extrapolate them, suggest as high as 25% of individuals that have pathologic MS show no expression of the disease at all. That would be the very mildest form. We also appreciate MS is a spectrum.

There's an entity called radiologically isolated syndrome or R-I-S, RIS, that's not yet recognized as an MS phenotype, but likely will be in the next diagnostic criteria revisions. This is a young individual who happens to get a brain MRI because they're participating as a healthy control in this study, where they have headache, or they have a concussion. Lo and behold, it's very abnormal, looking like MS. We know within five years, 35% will present with MS. Within 10 years, 51% will present with MS. This is detecting presumably silent MS.

We also now realize, and we're learning slowly about it, there's a prodromal stage to MS of maybe 5 to 10 years, where there's something going on health-wise, but there has not been a clear neurologic presentation. We know that MS exists for perhaps years before it presents.

When MS clinically presents and is diagnosed, in the variability, there will be people that have mild disease and people that have much more severe disease. One thing we know, and this is an important educational point, MS involves accumulating permanent damage to the central nervous system so long as the patient is not on treatment.

They may not be having attacks of the disease. They may not see worsening on the neurological exam. Even the MRI scan may remain stable, not showing new macroscopic lesions, but there's microscopic injury. I don't really like to call this disease relapsing-remitting MS because it does not remit. I refer to it as relapsing MS.

We have no way to identify who is so mild once they declare themselves as having MS. We have no way to determine who is so mild that they don't need treatment. It's a retrospective determination looking back 30, 40 years, and saying, “this person did well without treatment. They didn't need it.” It's a bad gamble, in my opinion.

If you have safe, well-tolerated, disease-modifying therapies, you will not want to gamble that you have mild disease, because if you gamble wrong, it's too late. We do not have the ability to reverse it.

There are very many interesting aspects to MS.

I spoke a bit in my talk about biosensors, monitoring that can allow home tracking of MS individuals, and what do I expect might come for that? Understand that when the patient comes to our outpatient department, we're seeing them for 15, 20, 30 minutes, and then they go home. We don't see them again for a couple of months.

Home tracking devices allow you virtually 24/7 over days, to weeks, to months, to look at various activities or monitor patients. There's been preliminary studies that suggest you can detect, by looking at physical activities and walking, that someone with relapsing MS may be transitioning to the more severe progressive form of MS by a slowdown in their tracking ability.

You can follow somebody for much greater lengths of time to get a better handle on actually what is happening. You are also allowed to sample a much larger number of patients where they can feed in data points and feed in information without needing to come to the clinic, and write things down, etc., but in real-time.

We have great hopes that biosensors and monitoring for more prolonged periods at home will give us a much better handle on the course and the nature of MS.

I also mentioned the gut microbiome studies. We are involved with that at Stony Brook. People in our MS center are collaborating with people in microbiology and molecular biology. This is a very interesting issue. It's in early stage. It's not just unique to MS. There have only been several hundred MS patients well-studied.

We know that the gut has a flora, and this gut flora is somewhat unique for every individual. This gut flora influences the systemic immune system, the mucosal immune system, and also influences the central nervous system. There's a real gut-brain circuit connection.

The very intriguing thing is the issue of whether there could be gut flora that promote development of MS, and changes in gut flora that could be driven that would treat MS or even protect against development of MS. This is in its infancy. It's being studied in other, in particular, neurologic diseases, besides MS. It's extraordinarily interesting and fascinating. Something may come of it that would be big, or nothing may come of it. We'll have to wait to see.

Another question I had was about the lasting impact of COVID-19 in individuals with MS, and have I seen any noteworthy symptoms from vaccinations? I would say the following: The COVID-19 pandemic brought home the value of telemedicine. We've not totally abandoned that and, hopefully, we will not. That in certain circumstances, telemedicine can be tremendously effective. Now, I would say that the good thing is that it appears that MS patients, in and of themselves, are not particularly vulnerable to getting COVID-19.

There are certain disease-modifying therapies that may make them a little bit more vulnerable, but we have not seen any major issues in this regard. We are really recommending vaccination to all of our MS patients.

If you do a risk-benefit analysis, there is not any reason for an MS individual not to get vaccinated, particularly if they have progressive MS, particularly if they're older individuals, particularly if they're disabled, particularly if they're of Black or Hispanic background, particularly if they have comorbid conditions that we know put individuals at greater risk for COVID-19, like diabetes, obesity, hypertension.

A very interesting recent study looked at a huge number of COVID patients, over 230,000, and they tracked them for the next 6 months to see how many had neurologic or psychiatric diagnoses. Thirty-four percent— particularly if they had bad COVID—34% had neurologic/psychiatric issues over the next 6 months. This is something that we need to really watch for.

The final question that I had, what were key takeaways from my IAS presentation? As I said, MS is the major neurologic disease of young adults. It should be suspected by primary care, general medicine, OB/GYN, in any young individual who is presenting with new central nervous system issues.

MS is a tremendous success story. Multiple disease-modifying therapies limit damage from this disease. We still have many unanswered questions, and we still do not have a cure for this disease. We know what causes MS is some interplay of genetics, environmental factors, and the host immune system, in addition to changes within the CNS that cause ongoing damage to the central nervous system.

I believe the cure for MS will await our truly understanding how these pieces of the puzzle for the etiology of MS actually fit together. In the meantime, we know that the earlier we start treatment, the earlier in the MS disease process, and the younger the age, the better the later outcome.

With close follow-up of patients, with a switch in disease-modifying therapy, if they've not done well, we are transforming the natural history of MS in our lifetime. I'm telling my patients now, I expect with diagnoses of relapsing MS, that they will be able to live a normal life.

I'm emphasizing the importance of wellness, and recognition, and best control of comorbid conditions to allow that individual to age better. That's a key component in fighting MS.