The Goals of Relapsed MS First-Line Treatment

Thomas P. Leist, MD, PhD: When assessing a patient in whom we think we have a relapse, what do we take into consideration? The first point is that it is obviously very important to ensure that the patient doesn’t have a worsening of neurological functioning because of a co-occurrence of another disease.

The second point to consider is when the symptoms started. Did they start within the past few days? Are the symptoms worsening? Is there a crescendo to the symptoms, or have the symptoms plateaued? If the latter were the case, we normally would not consider treatment of the attack unless the attack is severe enough. I’m thinking of a sensory attack. If the patient is still in the period when the symptoms are worsening and we have confirmed that there is no occurrence of another condition, then we consider treatment of this particular attack.

Considerations around treatment can include first-line steroids. Ultimate interventions could include plasma exchange, depending on local availability—very often, that requires hospitalization—or ACTH [adrenocorticotropic hormone].

A patient is diagnosed with a relapsing form of multiple sclerosis [MS]. Why do we consider treatment in this patient? It’s an important question. From my point of view, MS is, at this point in time, a treatable or manageable disease, and appropriate intervention at the earliest possible time can help us thwart the progressive form of multiple sclerosis. It may also help us prevent a patient from having disability accumulation. I’m talking about not just physical disability accumulation but cognitive decline. Essentially, the goal is to maintain the patient in a functioning state, as if they had no MS.

What is the goal of treatment with MS medications? The goal is to have as little manifestation of the disease as objectively reachable in a patient. If a patient has new lesions on a brain MRI [magnetic resonance imaging], treatment change should be envisaged. If the patient has a new attack, a treatment change should be envisaged. It becomes a bit more difficult when we think about cognitive changes, because for many of the agents, we don’t have the data to support this. Nevertheless, as a practitioner, if I have a patient that has changes that are impactful in their daily life—for example, with their job—I will consider treatment changes at that point in time.

Why is it important to diagnose MS early on? It is important to diagnose MS with certainty as early as possible, because we now have treatment options. All these treatment options can potentially prevent or reduce the long-term consequences of multiple sclerosis.

That’s why it’s important to diagnose early. It is not just to reach the diagnosis but also to come to the point where treatment can be offered to the patient. It is then important to assure us that the diagnosis is correct. In multiple sclerosis, we have a challenge in that we don’t have any specific disease markers to tell us that the patient has MS. It’s a constellation of disease activity, MRI, and exam findings that all need to be taken into account.

It is important when applying, for example, the 2017 McDonald Criteria for the Diagnosis of Multiple Sclerosis, to keep in mind that these criteria are only applicable in patients who fulfill certain clinical criteria. A patient with multiple symptoms that do not allow a localization of the disease activity needs to be approached with care before one gives a diagnosis of multiple sclerosis.