Optimizing Outcomes for Patients With MS

Matthew J. Baker, MD: In conclusion, Jeff, what are some take-home messages for those neurologists who are treating relapses in MS [multiple sclerosis]?

Jeffrey M. Kaplan, MD: So basically, the take-home message is “be particular.” Don’t accept an incomplete response. If a patient is put on high-dose oral or high-dose intravenous steroid medications and they don’t have a very good response, or if they have significant adverse effects and have to come off therapy early, please bring the patient back into the office quickly—within 7 or 10 days—or even do it through a telemedicine visit. We’ll talk about that in a second. Reevaluate them and give some very serious thought about 1 of these 3 other options that we spoke about: Repository corticotropin injection, which is better known as Acthar, or the plasma exchange treatments, or even IVIG. I think that’s incredibly important. I think it’s very important for patients…I tell my patients, “You need to be a very big advocate for yourself, not only in the relapse situation, but in MS in general. You need to be a big advocate for yourself. You need to try to force your doctor to get to what we call no evidence of disease activity. And also, make sure your physician is not accepting of an incomplete response to relapses.” I always tell my patients, “You have a responsibility in this illness, too. This is an illness that’s changing on a daily, weekly basis. You need to keep up with the National Multiple Sclerosis Society website, or some of the other good websites such as MSAA [Multiple Sclerosis Association of America], regarding multiple sclerosis so you remain current and are a good advocate.”

I also tell this to family members. I say, “Please keep up on this. Please learn about the different therapies.” And if you have to, I even tell this to my patients all the time: “Please, it does not hurt my feelings if you want to get a second opinion.” I know of some great doctors. I know a really good one in Naples, Florida—Dr Baker. I say this to them when I get into a situation with my patients where I’m not exactly sure what to do.

We have to have the humility to ask for help. And I say to my patients, “You need to be advocates.” Say, “Have you talked to this over with anybody else?” Or, “Do you feel like this is the best that I can do?”

Matthew J. Baker, MD: Do patients really understand what relapse is and how to define it, even despite your best efforts at educating? You give these patient programs and you talk with patients and care partners. You’re hammering home the definition of a relapse. How often do you find that it’s a hard concept for them to grasp, so they’re underreporting their relapse? Or, they’re afraid to tell you. They have concerns with the adverse effects of therapy. How often do you encounter those situations?

Jeffrey M. Kaplan, MD: Early on, when I start taking care of my patients. But I’m very blessed, because all of my nurses are MS certified. My nurse practitioners and PAs are MS certified. I always tell my patients, “Please call.” Or, we have a web-based program where they can send a message in. And I always say, “Let us decide what is concerning and what isn’t concerning.” I think that that’s so important.

But I definitely have had patients come into the office with new onset of weakness, or coordination issues, and I have said, “When did this start?” And they say, “Oh, it was about 2 or 3 months ago. I really didn’t think it was that big of a deal.” I really need to hammer that home.

And another thing is we really need to talk to the caretakers. As we know, a significant number of our patients with MS have cognitive impairment. And so, sometimes they will not be able to grasp the importance of these changes.

And even something as simple as cognitive impairment, itself, can be a symptom of a relapse. Again, that education part is huge and is very important for our future, since we’re developing such good treatments not only on the disease-modifying therapy end but are now developing better treatments for the acute treatment of the relapses. Patients, as I said, need to have high expectations.

Matthew J. Baker, MD: Wonderful. Well, this has been extremely informative. Thank you, Dr Kaplan, for this insightful discussion. And thank you to our audience for watching this NeurologyLive® presentation on expert perspectives regarding contemporary data on treating multiple sclerosis exacerbations. We hope you found this Peers & Perspectives® discussion to be useful and informative.

Jeffrey M. Kaplan, MD: Thank you so much, Matt.

Matthew J. Baker, MD: Thank you.