How is MS diagnosed?
Generally speaking, it's a clinical diagnosis. Patients present with a constellation of symptoms and then we do some testing. Numbness in an arm, tingling, visual problems and loss of vision in an eye are the most common symptoms. Other patients arrive at the hospital with more severe attacks involving paralysis on one side of the body or paralysis from the waist down.
Other patients present with fatigue and cognitive issues. You have to put all these symptoms together with an MRI (magnetic resonance imaging). We base our diagnosis pretty heavily on MRI. On the MRI, we see lesions, which look like little white spots, which are very characteristic of the disease. If MRI isn't enough to make a diagnosis, we can do a spinal tap, where we rule out a lot of other diseases that can mimic MS.
Do people with MS experience symptoms constantly?
Generally speaking, when MS patients are diagnosed, they have a relapsing-remitting form of this disease, which means they can have some symptoms and then the symptoms can go away. Some of the symptoms can be quiescent for 10 or 20 or 30 years, and we call this a remission.
But the interesting thing is, if you follow these patients' MRIs, their disease is not quiescent. We see new lesions that are coming, we see old lesions that are going. This means that the disease is actually quite active. What I think and what a lot of physicians think now is that it is this silent, constant bombardment of the nervous system that eventually doesn't allow the nervous system to bounce back. That's why, much later on in the disease, a lot of patients develop disabilities.
If we can shut this bombardment down with early treatment and continued treatment, we give our patients the best chance of a very good course with this disease.
What is the benefit of early treatment?
I would say the buzzword now with MS is early treatment and staying on treatment. That's because what we know about this disease from MRI shows that even when the patient is not experiencing symptoms, the disease is active and we think that has long-term consequences. There have been several studies to date showing that early treatment is not only effective, but it changes the course of the disease. If you get treated later, you never quite catch up.
Are some patients hesitant about starting treatment early?
By early treatment, I mean you should be diagnosed and treated almost in the same breath. Sometimes patients don't want to do that. They don't want to take injectable therapies, they don't want to stop denying this disease. But the interesting thing is that the patients who are protected actually do better and feel better because they have this umbrella of protection.
have a great story about a patient of mine who was diagnosed and didn't come back to see me because I really pushed treatment, and she didn't want to do it. She called me a year later, stating that she's numb on the entire right side, and she's crying. I said, "Don't worry, we'll take care of it, we'll treat you." And she says to me, "That's not the problem. Every single morning for the past one year, I've woken up worrying, 'Should I be on treatment? Shouldn't I be on treatment? Am I making a mistake?' And now I realize I've made a mistake." And from that point forward, she felt protected and she was on treatment and, psychologically, she did much better.
Will some patients do well without treatment?
There are a small percentage of patients who actually do well whether you treat them or not, but it's important to note that that's a small number of the patients. Only 5 or 10 percent of patients truly have a benign course to this disease. Although we all want to think we have the benign course, number one, we can't predict who really does have the benign course and, number two, the odds are not with you.
What treatments do you recommend?
Today, we're lucky enough to have four platform therapies: Avonex, Betaseron, Rebif, types of interferon, and Copaxone. These are the therapies that have been approved by the Food and Drug Administration (FDA) for relapsing-remitting disease. Novantrone is a newer therapy that has been approved by the FDA for progressive disease.
All of these drugs are able to decrease the likelihood of getting an attack of MS symptoms. They're also able to decrease the intensity of an attack if you have one, and they have a profound impact on the lesion burden seen on MRI.
What are interferons and how do they work?
Interferons regulate the immune system. They're very large molecules and, in order for the body to utilize them most effectively, they have to be given either intramuscularly or subcutaneously; they cannot be given orally. That's one of the difficulties that patients have with starting treatment, although once they've started, it's really a very simple process and patients don't have significant difficulty.
Interferons are quite well tolerated. In the first three months, it is possible to develop a flu-like syndrome.
What is Copaxone?
Copaxone also acts as an immunomodulator. It makes it less likely that you're going to have an inflammatory response or these white-matter lesions. It is also given subcutaneously daily and is extraordinarily well tolerated. It does not cause a flu-like syndrome, though it can cause skin reactions. It can also cause a systemic reaction in which, right after the injection, people feel like their heart is racing and that they're sweating. This has never been associated with any cardiac problems. It happens once or twice in about 5 percent of patients on Copaxone.
How effective is the Copaxone in comparison to the interferons?
In the phase III clinical trials evaluating relapse rate, Copaxone is as effective as any of the interferons. If you look at MRI data, the interferons decrease the number of new lesions and the lesion load over time by about 90 percent, and Copaxone does so only by about 50 percent.
What factors go into treatment decisions?
When I discuss treatment options with patients, I discuss specific issues to help them work with me on deciding which drug they're going to be taking. We look at efficacy of the medications with regard to relapse rate and MRI data. We look at the patient's disability and cognitive function. We look at quality of life. For example, which medication would be best suited for the patient if they're working or if they're taking care of children. We also consider neutralizing antibodies because that has long-term consequences with regard to the drug's efficacy.
What are neutralizing antibodies?
Neutralizing antibodies are proteins or antibodies that can develop when somebody is exposed to a certain protein or a certain drug. If you develop a neutralizing antibody, you neutralize the effect of the drug; the drug does not work any more. We know that, with Avonex, the likelihood of developing a neutralizing antibody is about 5 percent. With Betaseron, the likelihood is any where between 30 and 45 percent and, with Rebif, it's about 25 percent.
The problem is that if you develop this neutralizing antibody and you're doing well, one might not know that you have the neutralizing antibody because you're not having attacks. But if we follow patients on MRI, there seems to be some activity in the brain.
Why is the doctor/patient relationship important?
I think it's important for doctors to have patients come in frequently and discuss issues with the doctor and the nurse, so that we can keep patients on treatment. The worst thing is when someone doesn't come back to me for a year and says, "Oh, I stopped the drug six months ago because I couldn't tolerate it or because I got tired of injecting myself." You really need a support system. I think that's where the MS care center, the doctor and the nurse can really empower the patient and allow them to push forward.
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