Goals of Therapy for Relapsing MS

Matthew J. Baker, MD: Hello, and thank you for joining this NeurologyLive® Peers & Perspectives presentation titled, “Expert Perspectives: Contemporary Data on Treating Multiple Sclerosis Exacerbations.” Today we are going to discuss current data on treating patients who experience exacerbations in multiple sclerosis [MS]. I am Dr Matthew Baker, a neurologist practicing in Naples, Florida. Joining me today is Dr Jeffrey Kaplan, a neurologist practicing in Overland Park, Kansas. Thank you so much for joining us, let’s begin.

Dr Kaplan, I was wondering if you could start by maybe giving us an overview on our goals of therapy when treating patients with relapsing MS?

Jeffrey M. Kaplan, MD: I have to use this question as a platform for a couple of things. One that’s definitely been a mainstay of my therapy for many years is that we know there is a difference between what we call induction therapy in multiple sclerosis and escalation therapy in multiple sclerosis. As you know, escalation therapy has been a popular therapy for many years. We start with medications that have lower efficacy but lower risk. And then if patients break through, we move up a level. And then if people break through again, then we go up to the high-efficacy medications.

A low-efficacy medication would be something such as a medication that is an injectable. And then maybe the middle of the row would be oral medications. And the higher rows are usually infusible medications.

I fall under the theory of induction therapy. I feel it’s extremely important to start patients off on high-efficacy medications to control multiple sclerosis early on when the disease has more of an inflammatory component versus a neurodegenerative component. And so, this has been the mainstay of my therapy for a long period of time.

Matthew J. Baker, MD: When using these higher-efficacy medications, do you encounter relapses frequently or less frequently? And when you do see a relapse, what’s your approach to relapse therapy for those patients?

Jeffrey M. Kaplan, MD: So overall, I do see relatively fewer relapses with a high-efficacy therapy. But when I do see a relapse, my initial approach is always to start with intravenous Solu-Medrol [methylprednisolone], usually at a dose of 1 g IV [intravenous] for 5 days. And then one thing that’s very important to do in patients like this is to reevaluate them. Bring the patient back in about 7 to 10 days after the relapse starts to see how well they’ve done with the IV Solu-Medrol. That’s very crucial. And because of that, you might need to give additional therapy. So for patients who do not respond very well to the initial IV Solu-Medrol, I do have alternatives.

Matthew J. Baker, MD: What might those alternatives be, and are there other circumstances in which IV Solu-Medrol may not be a great option?

Jeffrey M. Kaplan, MD: My first choice is Acthar, and the official way of stating this is repository corticotropin injection. But as we know, Acthar is an intravenous injection that is basically made up of several adrenocorticotropic hormones and analogues and other pituitary peptides that stimulate corticosteroid production. It is an agonist for all 5 of the melanocortin receptors. It has anti-inflammatory and immunomodulatory effects.

Another choice we have is plasma exchange therapy. I will usually give 5 plasma exchange therapies over a period of 7 days. I usually treat based on the theory of 2 on, 1 off, 2 on, and 1 off. And then the final dose. And then the patient is able to be discharged at that time. Now, as we all know, life has changed tremendously over the last few months due to the COVID-19 [coronavirus disease 2019] pandemic. So, for the last few patients that I’ve done plasma exchange therapy on, I have been able to manage the disease via an outpatient procedure.

Sometimes I’ll initiate it as inpatient and then I will switch to outpatient therapy. The only disadvantage of that is the catheter they have is a permanent dialysis catheter. It’s a bit more painful for the patient, but they clearly prefer this instead of being in the hospital for 7 days.

And then lastly, 1 therapy that has not had as much proven efficacy but is still occasionally used by myself, and I know is occasionally used by several multiple sclerosis physicians, is IVIG therapy.

Matthew J. Baker, MD: Do you ever use high-dose oral therapy? Especially during this pandemic, patients aren’t enthusiastic about running to an infusion center or to the hospital for treatment. Has that been used at your practice at all?

Jeffrey M. Kaplan, MD: It has more recently, since there have been studies that have shown that high-dose oral prednisone or high-dose methylprednisolone in equivalent doses has been relatively effective. My patients do tend to have more adverse effects with that. They tend to have more gastrointestinal adverse effects with the oral versus intravenous therapies.

Matthew J. Baker, MD: A lot of pills to swallow every day, isn’t it?

Jeffrey M. Kaplan, MD: Yes, absolutely.