Multiple Sclerosis in Practice An Expert Commentary With Jeffrey Cohen, MD, PhD A Clinical Context Report
Clinical Context: Multiple Sclerosis in Practice Expert Commentary Jointly Sponsored by: and
Clinical Context: Multiple Sclerosis in Practice Expert Commentary This activity is supported in part by an educational grant from Teva Pharmaceuticals
Multiple Sclerosis Clinical Context Series The goal of this program is to provide upto-date information and multiple perspectives on the pathogenesis, symptoms, risk factors, and complications of multiple sclerosis as well as current and emerging treatments and best practices in the management of multiple sclerosis.
Multiple Sclerosis Clinical Context Series Target Audience Multiple sclerosis physician specialists, community neurologists, advanced practice healthcare professionals, primary care physicians, multiple sclerosis nurse specialists, nurse practitioners, physician assistants, pharmacists, and other allied health professionals involved in the care of patients with multiple sclerosis.
Activity Learning Objective Upon successful completion of this educational program, participants should be able to: Review the relevance and significance of the activity in the broader context of clinical care.
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Discussant Jeffrey Cohen, MD, PhD, Professor, Cleveland Clinic Lerner College of Medicine Director, Experimental Therapeutics Program Mellen Center for MS Treatment and Research Neurological Institute Cleveland Clinic Cleveland, OH
Disclosure Information Jeffrey Cohen, MD, PhD, has disclosed the following relevant financial relationships: Received Research Support: Biogen Idec; Genzyme; Novartis; Receptos; Teva Neuroscience Consulting/Advisory Board/DSMB: Teva Neuroscience This activity may review off-label or investigational information without any recommendation on their use.
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MS Drugs: Current Landscape First disease-modifying treatments: interferons and glatiramer acetate Effective, generally well tolerated, but not ideal Injection site reactions Flu-like symptoms with interferons Efficacy only modest Patients just don t like injections
Current Oral Drugs Fingolimod Oral Generally well tolerated But, rare serious side effects n Bradycardia at first dose n Macular edema n Liver abnormalities n Infection potential Teriflunomide
Natalizumab Given by infusion Very potent Well tolerated by most patients But, risk of PML
Need for a Treatment Algorithm Wide range of medications available now or in the near future A logical treatment algorithm for matching individual patients with the most appropriate drug is needed Not available yet, but may soon with help from biomarker data
Future Directions: Progressive MS Previous treatments focused on preventing relapses and lesion activity None clearly effective in preventing or slowing progressive forms of MS New treatments should be directed at this unmet need
Statins Recent study found that simvastatin improved outcomes in secondary progressive MS Earlier studies of statins have shown conflicting results Anti-inflammatory effect, plus possibly a tissue-preserving or tissue-repairing effect Statins warrant more study in progressive MS
Cell Therapies Hematopoietic stem cell transplant has been used to tame severe attacks. Other approaches now under study include adult stem cells, particularly mesenchymal stem cells.
Diagnostic/Prognostic Aids MRI has been extremely helpful for assessing patients with relapsing MS No comparable methodology now available for neuroprotective or repair strategies Looking at DTI, MTI, OCT; all show promise for measuring tissue integrity Already being used as endpoints in early studies of cell-based therapies
Alemtuzumab In the Nearer Term Long-acting infusion drug; given annually Double-edged sword : long action is convenient but raises concern about reversibility of adverse effects Causes autoimmunity in a few patients n Manifested as thyroid disease, more rarely thrombocytopenia or glomerular basement membrane disease Probably manageable with close monitoring
In the Nearer Term (cont d) S1P Modulators Fingolimod was first in class Others now in development Cardiac side effects are a class effect But, 2 nd -generation drugs can be titrated such that starting doses can be low Also relatively short-acting These features should keep serious cardiac effects to a minimum
In the Nearer Term (cont d) BG-12 (Dimethyl fumarate) Very few significant safety issues in trials Many patients show flushing or GI effects early on therapy; how much of a problem remains unknown May have potential for tissue preservation but this is unconfirmed
Summary Identify the current therapies for MS and their limitations Recognize that treatments to prevent or slow progressive forms of MS remain a major unmet need Discuss with patients the pros and cons of new MS treatments now in development, including alemtuzumab, BG-12, 2 nd -generation S1P modulators, and cell therapies