Multiple Sclerosis in the Community: Best Practices

Robert J. Fox, MD: When I see MS [multiple sclerosis] patients, I think about 3 different questions. One, do they have active inflammation? Is there a relapse going on? And in some patients, a lot of active inflammation on MRI [magnetic resonance imaging] that needs to be treated with steroids? Is there active inflammation or not?

The second is, is their therapy working? That therapy may be no therapy, or it may be a therapy. And so, I ask whether that therapy is working, and is the patient tolerating it?

Then the third question is, what symptoms were left by their MS that need to be addressed? There are a lot of symptoms that MS leaves behind. It can be bladder problems, bowel problems, walking difficulties, pain, spasticity, sexual dysfunction, depression. There are many symptoms that are left behind from MS, and almost all of them are amenable to some sort of treatment, whether it be medications, physical therapy, health psychology. For almost all of these symptoms, there is something we can use to help the patient be more comfortable. It's those 3 aspects of MS every time I see a patient: Is there active inflammation? Is the disease-modifying therapy the right one for them? And, what symptoms need to be addressed?

Fred D. Lublin, MD: We do educational programs so that all clinicians who are taking care of patients with MS can use the full array of available therapies. We're trying to get away from the idea of becoming comfortable with 1 therapy and using that as your go-to therapy. We don't think that's optimal MS care. Having said that, MS care has gotten very complicated. There is increasing monitoring that needs be done, both for disease activity and for safety of the various agents. And there's complexity in the dosing and in the route of administration. This is why we have MS centers. We happily partner with our colleagues in the community, understanding that we can provide a resource for them to make life easier.

I'm always impressed at how knowledgeable community neurologists are in treating MS. I'm impressed not because I don't think they should know it, but because they need to know what's going on in MS, Parkinson disease, Alzheimer disease, epilepsy, and headaches. Keeping up is difficult, so it's impressive to see. I think that, and I find this in my practice, MS centers such as ours and others around the country serve as useful resources for people in the community. We see people who live far away, who are sent in by their referring physician. We look over what's being done. We make some recommendations, and then they go back home to their referring physician. We keep in touch and try to develop optimal treatment programs for each individual patient.

Shared decision making is critical in the treatment paradigms for multiple sclerosis. The patient has to take the medication. If they're not on board with what you're doing, they won't take it. And if they don't take it, they're not going to do well. This is why you have that long conversation. To see what they're belief systems are, what worries them, what would make them feel better, and what aspects of the disease need to be treated. You have to make sure that you're treating their symptoms in addition to just treating with disease-modifying therapies. If you only treat their MS with disease-modifying therapies and don't treat symptoms, like spasticity and bladder dysfunction and pain and sexual dysfunction and spasms and things like that, the patient may get fed up with the therapy, even though the therapy is not really designed to treat the symptoms. It’s important to do that, and to take a truly holistic approach to what you're doing for the patient. That will keep them on board, and that will enhance adherence.

One of the things that we've seen is when individuals on a disease-modifying therapy come in with a flare-up, the first thing we ask them is, are you really taking your medication as it was prescribed? Very often, this is especially the case with the injectables, they'll say, “Well, no, I got tired of giving that injection 3 times a week. I cut down to once a week,” or something like that. It's very important that you go through the educational needs for the different agents so that people do adhere to their therapy.