Moving Toward a More Personalized MS Treatment Journey

Mitzi Joi Williams, MD

THIS IS INDEED AN EXCITING TIME in the field of multiple sclerosis (MS). As treatment options continue to expand—now with over 20 therapies, including options for primary and secondary progressive disease—the science in the field is focusing more on other issues such as understanding and tracking disease progression, approaches to treatment initiation, and the roles of diet and exercise in pathogenesis and disease course. This issue of NeurologyLive^® focuses on several of these topics.

There is an increasing volume of data characterizing the more severe disability seen in Black populations, but the roles of social determinants of health and underlying biology remain unclear. Our cover story, “Disproportionate Neurodegeneration in Black Patients With MS: The Need for Stratified Treatments” by Darin T. Okuda, MD, FAAN, FANA, examines evidence in the literature regarding both phenotype of MS in Black patients and imaging markers of early neurodegeneration. This piece highlights the importance of individualized treatment approaches but also raises important questions regarding how we approach therapeutic decision-making in populations that are known to have more aggressive disease. This extremely important topic emphasizes the dire need for increased diversity in clinical research to make results more generalizable and better understand disparate outcomes.

It has been well known that exercise provides cardiovascular benefit for patients living with MS, but the prescription of exercise training to help with specific symptoms of MS including fatigue and cognitive dysfunction is less well known. In the feature story “Exercise Training in Multiple Sclerosis” by Robert W. Motl, PhD, he discusses the role of exercise training in MS and our current understanding of its benefits. Motl also provides interesting perspective and a review of studies focused on exercise training as a disease-modifying intervention for MS, as well.

As treatments become more effective, it has become more imperative to track effectiveness, but also disease progression. Torge Rempe, MD, and Tirisham Gyang, MD, provide an overview of available and emerging biomarkers in MS in their feature article. This piece first describes the role of biomarkers and qualities of good biomarkers. The authors discuss current well-known markers such as MRI, cerebrospinal fluid oligoclonal bands, and optical coherence tomography and how they can be used in both diagnosis and evaluating treatment response. The article also covers emerging biomarkers such as glial fibrillary acidic protein and neurofilament light chain and the potential utility of these markers once they become more widely available in clinical practice.

As the therapeutic landscape becomes more complex, it becomes even more imperative that we engage in shared decision-making with our patients and their care partners to create the best individualized treatment plan possible. This plan should include early intervention with disease-modifying therapy, although there is not sufficient evidence to fully support escalation therapy versus early high-efficacy therapy. As evidence unfolds focused on the effects of diet, the gut microbiome, exercise, and comorbidities, these issues will also become more integral in initial and ongoing treatment plans.

We have not yet attained the ability to practice precision medicine in MS, but the scientific community is moving us closer to this goal. As we set our sights on moving past preventing disability to examining clinically definite improvement and reaching no evidence of disease activity as a treatment goal for our patients, we need a comprehensive approach to treatment that focuses not only on disease-modifying therapy but also modifiable risk factors and wellness. Improving health outcomes for all ethnic groups and better understanding MS characteristics in minority populations will also play a key role in improving health equity in these populations but will hopefully lead to discoveries that allow us to increase quality of care for all people living with MS.