NeuroVoices: Nancy Sicotte, MD, on Changes to the Understanding, Education of Multiple Sclerosis

Nancy Sicotte, MD

Launched in 2003, National MS Education and Awareness Month is observed in March of each year as a nationwide effort by the Multiple Sclerosis Foundation and affiliated groups to raise the public’s awareness of multiple sclerosis (MS), a disease that affects nearly 1 million people in the US. The main goal of the campaign is to promote an understanding of the disease, and to assist those with MS in making educated decisions about their healthcare.

Since it was first described in 1873, there have been several significant milestones in the treatment of this condition. In 1981, the first MRI pictures of a brain affected by MS were produced, revolutionizing MS diagnosis. Years later, in 1993, the first disease-modifying therapy for relapsing MS was approved. MS experts, including Nancy Sicotte, MD, believe we are at a pivotal moment in time in which substantial progress has been made towards treatments, with new emerging concepts starting to enter the fold.

In honor of National MS Education and Awareness Month, NeurologyLive^® sat down with Sicotte to discuss the changes seen in the MS community, and how they are translated to the up-and-coming generation of neurologists. Sicotte, chair of the Department of Neurology at Cedars Sinai Medical Center, provided background on the difficulties of choosing optimal therapies, the transition towards observing more pathophysiological mechanisms than disease states, and some of the top advancements in the diagnosis of MS relative to other autoimmune disorders.

What are some of the most notable advances or changes in our understanding of MS over the last decade or so?

Nancy Sicotte, MD: Neuroimmunology, and MS in particular, has been transformed in the last two decades. I've been doing this for about 25 years. When I started, it was just the onset of the therapeutic era with interferons, and we now have more than 25 highly effective therapies to treat multiple sclerosis. This has transformed the way we think about the disease. We've also had great strides in diagnosing MS very early in the course, and having the knowledge and confidence to know that we can impact outcomes by starting highly effective therapies from the get-go. This has translated into wonderful improvements in outcomes for patients who live with Ms. For those of us who've been doing this for a while, we see that tangibly.

The other thing I would say about the field of neuroimmunology is that we now recognize there are other diseases that may look like MS, but are not MS. In particular, I would say the identification of the aquaporin-4 antibody that allowed us to differentiate neuromyelitis optica, from other MS mimics or even from MS itself, was really critical. That changed the way we think about biomarkers and demonstrated the power of a biomarker. We realize that these clinically defined syndromes that sometimes are missing the mark. In MMO, we used to think that you are not allowed to have brain lesions. If you had brain lesions, you couldn't have NMO. Now we know they're part and parcel of the syndrome. None of our residents are allowed to graduate without recognizing intractable vomiting and hiccups as a possible presenting sign for neuromyelitis optica. Because the stakes, of course, are very high. Now, we've gone from having a clinical description that was probably not very accurate to now a biomarker and now FDA approved therapies for neuromyelitis optica. That's another great example of how much progress has been made in this field.

How do you help young neurologists disseminate through the numerous treatment options for relapsing forms of MS?

We go through a particular process. We know that the therapies we use for disease modification accrue their benefits over weeks and months and years, not days. You must pick a therapy that the patient is comfortable with, that they're going to be able to tolerate, and that they're going to be able to use consistently. We also take into consideration things like lifestyle and plans for reproduction, for example. For women, that's going to dictate whether some medications are a good choice or not. That's part of the art. We are mainly diagnosing relapsing patients when they present, although we do, of course, have progressive patients, who continue to be a real challenge, and are one of the great unmet needs in the MS community. That requires more detailed conversation, and honestly, for a new presentation, it requires a lot more critical thinking about diagnosis to make sure that we're making the right diagnosis, especially in cases of progressive disease. This is where I think some of what makes neuroimmunology an attractive yield for a lot of our trainees, because there is a lot of patient education, patient interaction. There's a lot of shared decision making. There's an interesting pathophysiology. We have imaging, and now we have these great therapeutics. But there's also this human part of it and the interaction with the patients and the patient population that I think makes it a particularly attractive area for our trainees.

As the space starts to potentially move away from clinical phases, what impact does this have on education?

Certainly, the definition of MS in terms of which patients should be treated and what patients might benefit from treatment has changed. We looked now for active disease. Active disease can be defined even if people are having progressive disability. But if they have new inflammatory activity, whether it's relapses or new activity on their scans, that is definitely an indication that therapies that are anti-inflammatory can have a benefit. Where the field is now is trying to understand more of the compartmentalized inflammation that we think could be a real driver of this progressive disability that patients continue to experience despite these very effective anti-inflammatory treatments.

We're excited about some of the research. We work a lot on biomarkers here at Cedars for both diagnosis and a lot of the work we've been doing in the central vein sign has been impactful. We're excited about the CAVS-MS study that was just fully enrolled, but also on the other end, looking at other markers for compartmentalized inflammation like paramagnetic rims, lesions and some other studies that indicate there may be some ways to both identify patients early on who might be prone to having more progressive disease in the future, and then also as a biomarker for treatment effects. We're starting to be much more sophisticated in the way we think about the disease. The disease has multiple components to it, both the initial inflammatory processes, but then all the things that are going on within the brain and within the spinal cord that are compartmentalized. So far, our therapies haven't been able to directly impact that, so I think that's the next frontier.

Transcript was edited for clarity. Click here for previous iterations of NeuroVoices.