<p>Relapsing multiple sclerosis (MS) can present differently across patients, and many treatment options are now available to individualize the approach to the management of relapsing MS. Our featured experts discuss the current landscape of relapsing MS therapy and considerations for personalized treatment.</p>

I think that all of us strive to personalize the approach to relapsing MS management. Relapsing MS is a heterogeneous disease, manifesting differently and varying in severity and disease course from individual to individual. The unpredictability of relapsing MS often means a lot of anxiety for patients, and this is often its most difficult feature. Any individual with a new diagnosis of relapsing MS often wants to know what the future holds for them. Can we predict what is going to happen? Can we personalize a treatment plan for them?

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Characterizing a patient’s disease involves taking a history of what has happened to them before, performing a physical examination to determine which systems have been affected and how, and performing tasks such as imaging. Magnetic resonance imaging scanning is obviously a cornerstone of what we do to characterize the existing disease burden, but new blood-based biomarkers such as neurofilament light chain (NfL) are also now available to help identify the extent of disease activity. In my experience, when the levels of these types of biomarkers are high at the beginning of someone’s disease course, this is additional strong evidence to put in front of a patient that they need to get on a disease-modifying therapy (DMT). From there, developing a strategy that personalizes that patient’s treatment is important.

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For me, it then comes down to informing patients about the current state of relapsing MS management and what has been important to other patients and then involving them in decision making regarding what might be right for them. In my practice, we have arrived at much more of a final common path for managing relapsing MS with highly effective DMTs in newly diagnosed patients. However, once someone has been identified as being a candidate for highly effective DMTs, there are multiple different potential routes of administration and different dosing frequencies, so we do try to tailor this with the patient’s input in terms of what will fit them best.

Every patient we treat gets personalized medicine because no 2 relapsing MS cases are the same. We may employ similar strategies with shared decision making—not necessarily a standard approach, but rather very much individualized, which involves considering all the potential agents. Part of the problem, besides the fact that each patient is a little different, is that our ability to prognosticate is terrible. There are a lot of people who think that they can prognosticate relapsing MS, but too many times they are fooled. However, the whole idea is to individualize treatment and its many different factors, and part of shared decision making is understanding whether the patient is leaning more toward wanting the most effective therapy possible vs being more worried about safety.

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While we are still learning about how to use biomarkers such as NfL, they can sometimes give me an idea of what the underlying activity is when other metrics are not as clear. In addition, NfL can also be helpful when trying to differentiate between a pseudorelapse and a real relapse, but the dynamic of the biomarker is still somewhat obscure. All the care that we give to patients with relapsing MS should be personalized based on the knowledge that we have, with the understanding that there is much more knowledge that we need.

One of our major goals is to help patients select a therapy that is going to be successfully used over the long-term. In the early days of relapsing MS care, patients cycled through different therapeutics because there were not many to choose from. However, now that we have more than 20, I think that patients are here to get some guidance on how these might be used. So, you have to take all the elements that you obtain from the history, the examination, learning about what is going on in their lives, and listening to their goals and then try to distill that into options that you can discuss in more detail. My goal now is to try to find the therapy that will provide long-term success without having to cycle through a lot of different therapies.

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It is really our job to educate the patient on why we are leaning toward certain options vs others while being open to facilitating a discussion during which, if they have concerns, you draw those concerns out and make adjustments. I will tell a patient, “You are the one who needs to take the medicine. I can make recommendations, but I want you to be on something that you are going to be comfortable with and that, hopefully, you are going to be on long-term.” That said, if they must switch therapies for whatever reason, then, certainly, there is a very low threshold to do so.

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Immunophenotyping to determine what a patient might respond to the best has been a big goal in the field of relapsing MS for quite some time, but we are not quite there yet. However, I think that we are going to get some new tools with some biomarkers that are gaining traction in clinical practice, including some inflammatory parameters that may be beneficial in the future for figuring out if a patient may benefit from a more acute or a chronic anti-inflammatory therapy. I also think that imaging has served us quite well regarding prognosis and treatment selection and may even have a role in helping us decide where people sit in terms of more acute vs chronic inflammation. So, I think that we have come a long way. We have been incorporating a lot of tools so far, and I think that there will be some more coming up in the near future.