expert roundtables

Recent Advances in Multiple Sclerosis

by Robert A. Bermel, MD, MBA; Malcolm H. Gottesman, MD; and Eric C. Klawiter, MD, MSc

Overview

From B-cell–depleting monoclonal antibodies to sphingosine-1-phosphate receptor modulators, the diversity of the available high-potency therapies is recognized as a major advance in multiple sclerosis (MS). Nontreatment advances have also emerged.

Q:

What are the most important advances in MS that you have seen in the last decade?

Malcolm H. Gottesman, MD

Chief Emeritus, Division of Neurology
Winthrop Comprehensive MS Care Center, NYU Langone Hospital
Professor, Department of Neurology
NYU Long Island School of Medicine
Mineola, NY

“Certainly, the diversity of the available high-potency drugs, including the B-cell–depleting therapies and the sphingosine-1-phosphate receptor modulators, has been a very important advance.”

Malcolm H. Gottesman, MD

Certainly, the diversity of the available high-potency drugs, including the B-celldepleting therapies and the sphingosine-1-phosphate receptor modulators, has been a very important advance. Changes in the diagnostic criteria allowing for the earlier diagnosis of MS have also been important. MS can now be diagnosed more frequently at the time of first clinical event as a result.

Additionally, there may be advances that stem from our experience with COVID-19. Telemedicine—if it continues to be funded—has the potential to provide expert MS care to isolated patients, those who may be residing in skilled nursing care facilities, and those who would otherwise lack access to care. And I think that the technology behind the RNA-based COVID-19 vaccines has great potential. The ability to deliver mRNA and manipulate a lot of the molecular scenery, if you will, is very intriguing in that you could change the immunologic composition of the critical areas of many cells in the central nervous system or in the immune system. It is a potent technology, and I hope that someone comes up with something clever in terms of how to do it to help patients with MS. However, the best thing that we have at the present time is the prevention of damage. We are not quite there yet with repair.

Eric C. Klawiter, MD, MSc

Associate Neurologist
Massachusetts General Hospital
Associate Professor of Neurology
Harvard Medical School
Boston, MA

“. . . we now have emerging evidence indicating that starting with a higher-efficacy treatment results in improved long-term outcomes in our patients with MS.”

Eric C. Klawiter, MD, MSc

Regarding treatment advances in the last decade, I would say that the use of the B-cell–depleting monoclonal antibodies has made the biggest impact. This is a group of highly effective treatments with overall favorable safety profiles. These realizations have shifted the overall philosophy of treating newly diagnosed patients with MS (ie, early disease). In the past, the general paradigm involved escalating treatment as needed. There was an overall dynamic in which lower-efficacy treatments were regarded as the safest treatments and higher-efficacy treatments were regarded as less safe. The prevailing approach was to start with the lower-efficacy treatments and then to escalate to the higher-efficacy treatments only if necessary. However, we now have emerging evidence indicating that starting with a higher-efficacy treatment results in improved long-term outcomes in our patients with MS.

From the nontreatment perspective, I think that the greatest advances have been in our understanding of the pathophysiology of MS. One of the major contributions over the past decade has been the appreciation of the role of cortical disease in MS and how it evolves over the course of the disease. Advances in this area have related to the improved detection of cortical pathology in vivo with imaging. Over the next decade, we may be incorporating that information into diagnostic criteria and treatment evaluations.

Robert A. Bermel, MD, MBA

Director
Staff Neurologist
Mellen Center for Multiple Sclerosis
Cleveland Clinic
Cleveland, OH

“Regarding nontreatment advances, the progress with telemedicine has allowed patients and MS centers to better connect with each other, which has had an enormous impact.”

Robert A. Bermel, MD, MBA

I agree that an appreciation for the efficacy and safety of B-cell therapies in MS is, by far, the most important therapeutic advance over the last 10 years, especially considering how this realization has informed our understanding of the MS disease process. Previously, the conventional wisdom was that B cells were not fundamental to the MS disease process and that the efficacy would not be there. That certainly has been proven wrong because B-celldepleting therapies clearly are among our most effective therapies.

Regarding nontreatment advances, the progress with telemedicine has allowed patients and MS centers to better connect with each other, which has had an enormous impact. MS centers are the places where the greatest appreciation of the latest knowledge about MS exists; however, it is a challenge for many patients to physically get to an MS center. Telemedicine use has accelerated during the COVID-19 pandemic, and this has broken down many MS care access barriers, regulatory barriers, reimbursement barriers, and technological barriers. I think that patients and health care providers at MS centers recognize that telemedicine is useful in that it can improve one’s access to important decision-making tools and to the latest advances in MS treatment.

The most advanced MS care in the world cannot help our patients if they cannot access it, and telemedicine helps to solve that. There was a point in the pandemic when most of our visits were done via electronic virtual visit mechanisms, and we only brought patients into the clinic if we truly felt that they needed to be there. Now, the pendulum has swung back somewhat in that approximately 40% of visits are virtual and 60% are in person. I believe that virtual visits for MS care are here to stay in one form or another.

References

Florou D, Katsara M, Feehan J, Dardiotis E, Apostolopoulos V. Anti-CD20 agents for multiple sclerosis: spotlight on ocrelizumab and ofatumumab. Brain Sci. 2020;10(10):758. doi:10.3390/brainsci10100758

Goldschmidt C, McGinley MP. Advances in the treatment of multiple sclerosis. Neurol Clin. 2021;39(1):21-33. doi:10.1016/j.ncl.2020.09.002

Matthews PM, Block VJ, Leocani L. E-health and multiple sclerosis. Curr Opin Neurol. 2020;33(3):271-276. doi:10.1097/WCO.0000000000000823

Schwenkenbecher P, Wurster U, Konen FF, et al. Impact of the McDonald Criteria 2017 on early diagnosis of relapsing-remitting multiple sclerosis. Front Neurol. 2019;10:188. doi:10.3389/fneur.2019.00188

Thompson AJ, Banwell BL, Barkhof F, et al. Diagnosis of multiple sclerosis: 2017 revisions of the McDonald criteria. Lancet Neurol. 2018;17(2):162-173. doi:10.1016/S1474-4422(17)30470-2

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