Goals of Therapy in Multiple Sclerosis

Barry Hendin, MD: The goal of treatment for me is to reduce or diminish inflammation as early and as effectively as I possibly can. My belief is that even at best, when we treat multiple sclerosis [MS] early and effectively, some people will still progress, but I believe that the likelihood of progression and the speed of progression are diminished by early and effective treatments. In terms of what I want to do, I want to modify the disease. Modifying the disease means to reduce inflammation as early as I can and reduce the likelihood of attacks or relapses as early and completely as I can, and by so doing, reducing progressive disability.

Amit Bar-Or, MD, FRCP, FAAN, FANA: One of the important transformations in the MS field relates to expectations, both in terms of people living with MS as well as care teams and their treatment. We used to expect someone who had MS and was on one of the first-line immune therapies to experience a decrease, on average, in new MS activity and injury by about 30% or 40%. Now that we have many more treatments available, including much more effective treatments, the bar is set higher. We realize also that there’s a great extent of injury that occurs under the surface, and we became, as a community, much less tolerant of injury to the central nervous system [CNS]. And the axiom ‘time is brain’ is very appropriate in this context. Anything that we can do to proactively limit new injury, and ideally stop it completely, in individual patients has now become the preferred approach of most clinicians following patients with MS.

Barry Hendin, MD: I began treating MS early in my career before there were any disease modifying therapies. The first disease modifying therapy entered the market in the United States in 1993. I began practicing before 1993, and as such I saw a number of people for over a decade who had no effective disease modifying therapy. Their outcomes in my practice—their outcomes when looked at in epidemiologic studies—were much worse. Most of us are really grateful that even though we haven’t perfected our treatment of MS, we’re so much further along the line than we were. I think we do treat earlier. I think we do treat more effectively. I think we do achieve less progression.

Amit Bar-Or, MD, FRCP, FAAN, FANA: Treating early is a very important concept in multiple sclerosis. We know that from multiple clinical trials that had designs that included delayed initiation of treatment. So one arm might start a treatment earlier, while the other arm might start it in a delayed fashion. Those who received delayed initiation of multiple different treatments never catch up. They develop disability that persists and is built upon without being reversed. So we are still a ways away from fixing things that are broken within the central nervous system. And the imperative nowadays, which is a very real one, is to limit any new injury as much as possible in individuals. The earlier that we can do this—and as long as we can do this reasonably safely—the better.