Moving the MS Treatment Paradigm Forward

Peter L. Salgo, MD: All right, let me ask a deceptively simple question before we go. Using the outcome measures that we talked about, are we getting better outcomes with the newer agents? And is there a role for NEDA [no evidence of disease activity] as the primary endpoint?

Patricia K. Coyle, MD, FAAN, FANA: Well, we are getting better outcomes when you look at decreasing transition from relapsing to secondary progressive disease, check; better outcomes with regard to significantly decreasing late disability 10 years-plus out with early treatment, check; and all the studies showing patients are doing better with early versus delayed treatment. I think all those studies are pointing in the right direction, and I think we follow patients closely. We’ve been given our marching orders. If a year on treatment you have 1 or more attacks or worsening on examination, or 2 or more MRI [magnetic resonance imaging] lesions, that triggers a discussion about switching the disease modifying therapy.

Thomas P. Leist, MD, PhD: We talked about NEDA before. It may be too stringent as a measure. Particularly, what NEDA are we talking about? The NEDA-3 that we talked about with relapse is disability, progression, and MRI; or should we look at the NEDA-4, brain atrophy? Should we look at no disease activity with also cognitive decline? I do think that this is perhaps a bit too stringent for clinical practice to be applied. The goal is thresholds of disease activities that we don’t want to see, and then we need to switch to another agent or discuss switching to another agent.

Peter L. Salgo, MD: This has been a great discussion. Clearly, we can’t cover everything in 1 broadcast, but it’s been fascinating. And before we leave and before we end this discussion, what I want to do is get some final thoughts from each of you. You’ve got 30 seconds or so, and we all promise not to interrupt, which is a big promise in this broadcast, by the way. So Dr Coyle, why don’t you start?

Patricia K. Coyle, MD, FAAN, FANA: Two things. Early treatment means within 6 months of the first attack you want them on what you feel is the optimized treatment. Don’t neglect talking about wellness and the value in promoting CNS [central nervous system] health.

Peter L. Salgo, MD: You’re up.

Thomas P. Leist, MD, PhD: Diagnostic certainty in the beginning, ensuring that the diagnosis is right, and then most effective therapy early on for the patient. That would require potentially getting rid of some of the step edits.

Peter L. Salgo, MD: You got the last word.

Maria Lopes, MD, MS: I’m encouraged by what I’m hearing from the experts as hopefully a more consistent approach to the evaluation and management and the follow-up, so that hopefully we can also improve on the outcomes.

Peter L. Salgo, MD: Wow, this has been great. Thank you all so much for being here. Tremendous contributions from everybody. On behalf of our panel, I want to thank you for joining us, and I hope that you found this Peer Exchange discussion to be useful and informative. I’m Dr Peter Salgo, and I’ll see you again next time.