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CMSC symposium weighs factors in choosing between MS therapies (CMSC 2015)

Though clinicians can use a variety of factors to guide their choice of MS therapy, patient preference should weigh into the decision-making process, according to a symposium presented at the 2015 Annual Meeting of the Consortium of Multiple Sclerosis Centers. The conference was held May 27–30 in Indianapolis.

Stephen Krieger, MD, of Mount Sinai Medical Center in New York, opened the presentation – entitled Tried-and-True Vs. New: Weighing Your MS Treatment Options – by reshuffling the list of current therapies according to various merits, like their safety or efficacy. For clinicians who put a priority on treatments with a long track record for treating MS, glatiramer acetate and interferon beta-1a and -1b topped the choices, Dr. Krieger said.

As the symposium continued, the focus shifted to the challenges of choosing an approach to the patient with clinically isolated syndrome (CIS). Jacqueline Bernard, MD, of the University of Chicago noted that managing CIS is a common scenario for MS specialists, since at least 85 percent of MS patients present with a single isolated episode of demyelination.

Research has found that interferon beta-1a or -1b, glatiramer acetate, and possibly vitamin D can delay onset of clinically definite MS. When discussing a case study of a patient with newly diagnosed CIS, she recommended a disease modifying therapy (DMT) and vitamin D, with a repeat MRI in six months to evaluate her response to treatment. Importantly, the patient should have a role in deciding which DMT to use.

While managing patients with long-term MS, clinicians should consider whether their complaints are related to their MS or other factors, urged Marie Namey, APRN, MSCN, of the Mellen Center for MS Treatment & Research in Cleveland.

Treating MS “takes a village,” she noted. Patients often look to their MS specialist to treat symptoms that might be better handled by a primary care provider or other specialist, she said. One example she discussed was a patient who’s been dealing with MS for nearly 30 years and complains about bladder issues, cognitive changes, and injection fatigue.

This patient would benefit from a “tune-up” that might require rehab therapy, bladder evaluation, a visit with a social worker, and neuropsychological testing, Namey said. Another reasonable approach might be to consider switching to an oral DMT to increase her satisfaction with her regimen.

At several points, the conversation turned to the potential that biomarkers might offer in the future for influencing therapy choice. The main biomarker that clinicians can currently use to guide this decision is the patient’s JC virus status, said Michael Racke, MD, of Ohio State University, who spoke about treatment options for patients with relapsing-remitting MS. Typically, a positive status discourages clinicians from choosing natalizumab, due to concerns about progressive multifocal leukoencephalopathy.

“Some patients will just say, ‘I want to do this treatment because it seems like the safest one.’ If we had biomarker data that could influence that, it would make a big difference for patients in terms of how to influence the choice of treatment,” he told Elsevier.

Dr. Krieger echoed those sentiments about the value of the JC biomarker. “The JC virus antibody is the best biomarker we have in our field right now. It’s fundamentally positive or negative, and it affects the risk-benefit ratio of natalizumab 100-fold. That’s incredible,” he told Elsevier. “I think that’s sort of the goal of a biomarker: to be binary and to tell us something that impactful about customizing the benefit/risks for a given person.”

As the field searches for valid new biomarkers, patient input provides an important indicator in the meantime, Dr. Krieger said. “Until we have biomarkers that allow us to pick medicines really based on the individual biology, I think we can wisely choose medicines on the basis of individuals’ preferences and treatment goals, and our own comfort with the array of medicines that we have.”

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About the Editors

  • Prof Timothy Vartanian

    Timothy Vartanian, Professor at the Brain and Mind Research Institute and the Department of Neurology, Weill Cornell Medical College, Cornell...
  • Dr Claire S. Riley

    Claire S. Riley, MD is an assistant attending neurologist and assistant professor of neurology in the Neurological Institute, Columbia University,...
  • Dr Rebecca Farber

    Rebecca Farber, MD is an attending neurologist and assistant professor of neurology at the Neurological Institute, Columbia University, in New...

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