Multiple sclerosis (MS) is a chronic disease that affects the central nervous system, affecting signals between the brain and spinal cord and other parts of the body. This medical condition affects almost 2.5 million people worldwide and around a million people in the US. Depending on the person, MS can leave you feeling tired or weak. You may find you have difficulty with coordination and concentrating or remembering things. Other MS patients experience chronic pain, numbness, tingling, and blurred or double vision. In severe cases, it can cause tremors or even paralysis or blindness.
The most common form of MS is relapsing-remitting MS (RRMS). In this form of MS, a patient will have periods of flare-ups of the disease followed by partial or complete remission periods.
Treating MS
One of the most difficult things to predict is the disease progression in any one patient, what symptoms they will develop, and how severe they will be. Doctors have therefore been cautious about what treatment options they use and any adverse effects they may have.
Wait and See Approach
In the past, most neurologists preferred a wait-and-see approach to treating MS. This approach recommended a slow and steady escalation of treatments and therapies, constantly monitoring patients to see their effectiveness and watch for any adverse reactions.
In this approach, if there was evidence to show that specific therapies were helping or not, the doctor could then move to different, stronger, or more effective drug treatment. This approach also stops RRMS patients who don’t need stronger medication from being exposed to the stronger drugs’ common side effects and safety concerns.
Highly Effective Treatment Early Approach
A newer approach is called “highly effective treatment early approach” (HET). Here, RRMS patients are treated with stronger, more highly effective therapies from the earliest stages of their condition. The argument is that no neurologist can predict the course and effects of the disease, and their ability to assess if further damage is occurring to the nervous system is limited. By treating the symptoms earlier, there is a chance of limiting the future effects of the disease.
Typically, more aggressive treatment will only be administered to MS patients with intense symptoms. Similarly, those who were given a poor prognosis after their initial diagnosis due to various factors and indicators have also been prescribed higher efficacy therapies.
Escalation vs. Early Intensive
The debate about which approach is better for MS patients is ongoing. Much of the discussion centers around changes over time in a patient’s Expanded Disability Status Scale (EDSS). The scale, which Dr. John Kurtzke developed in the 1950s, measures the disability progression of MS patients. The higher your EDSS score, the less ability you have to do functional tasks such as walking.
In a 2019 study conducted in the UK, researchers examined the five-year disability outcomes for patients given traditional escalation therapies versus those given early intensive therapies. Those treated with escalation therapies were given moderate-efficacy treatments, and patients in the early intensive group were given high-efficacy medications. While the results were not conclusive, the study did indicate that long-term outcomes were better for patients who had been treated earlier with highly effective drugs. The researchers concluded that there was a need for further clinical study in this area.
A 2020 Danish study also concluded that using highly effective therapies as an initial treatment method produced a lower chance of EDSS worsening when compared to medium-efficacy therapies. It also showed a slower progression of disability.
If current evidence seems to point towards HETs as the best form of treatment, then why aren’t neurologists and patients using this approach? The answer appears to lie with risk reduction. For many doctors and patients, the potential risk of significant adverse effects such as liver damage, stroke, and infections associated with HETs is too great when weighed against the benefits. Add to that the safety issues with many of the medications, and most doctors and patients seem to favor the safety-first approach when it comes to MS treatment.
Written by Chaim Ford
References
- Multiple Sclerosis FAQs
- An argument for broad use of high efficacy treatments in early multiple sclerosis
- Kurtzke Expanded Disability Status Scale
- Clinical Outcomes of Escalation vs Early Intensive Disease-Modifying Therapy in Patients With Multiple Sclerosis
- Initial high-efficacy disease-modifying therapy in multiple sclerosis