Treatment Strategies in Multiple Sclerosis
Multiple sclerosis (MS) is one of the leading causes of disability among young adults and presents a major health burden in the USA and other Western countries. Disease-modifying therapies (DMTs) for MS are primarily aimed at reducing relapse rate and dis
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1 Introduction Multiple sclerosis (MS) is one of the leading causes of disability among young adults and presents a major health burden in the USA and other Western countries. Diseasemodifying therapies (DMTs) for MS are primarily aimed at reducing relapse rate and disability accumulation over time, and have been shown to significantly decrease disease activity clinically as well as radiographically on MRI. In the past several years, the number of therapies for this debilitating disease has greatly increased, offering the ability to tailor treatment plans based on severity of disease, personal preference, risk tolerance, and comorbidities. However, new treatments also come with new safety concerns and monitoring requirements with which physicians must familiarize themselves. This chapter will review the data regarding the treatment options currently available. Finally, while the armamentarium of treatment options for relapsing forms of MS has expanded over the past few years, no currently a vailable therapy has been efficacious in the treatment of (primary or secondary) progressive MS
A. Harel (*) • I. Katz-Sand Corinne Goldsmith Dickinson Center for Multiple Sclerosis, Icahn School of Medicine at Mount Sinai, New York, NY, USA e-mail: [email protected] A. Miller (ed.), Handbook of Relapsing-Remitting Multiple Sclerosis, DOI 10.1007/978-3-319-40628-2_4, © Springer International Publishing Switzerland 2017
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without relapses, and emerging treatment strategies are aimed at addressing this issue (see Chap. 5).
4.2 Initiating Therapy Accurate diagnosis and early treatment with DMTs are imperative in the management of MS. The increased availability of MRI over the last decades has allowed for the diagnosis of MS earlier in the disease course (see McDonald Criteria in Chap. 3), often after only a single clinical attack. Moreover, even in patients with clinically isolated syndrome (CIS) who fall short of formal MRI criteria for the diagnosis of MS, the presence of characteristic brain MRI lesions portends a high risk of conversion to clinically definite MS (CDMS) [1]. Numerous studies have shown that early initiation of DMTs in these high-risk patients with CIS leads to a robust delay in conversion to CDMS, conversion to MS (via McDonald Criteria), and development of new MRI lesions [2–6]. Furthermore, earlier treatment with interferon (IFN) β-1b led to sustained benefit in cognitive performance [7]. Therefore, it is widely accepted that high-risk CIS patients should be treated early with a DMT. Conversely, in the case of a patient with CIS and no lesions on MRI, the risk of CDMS is relatively low, and most providers would opt to forgo treatment in favor of close monitoring with serial exams and MRIs. However, because the presence of oligoclonal bands (OCBs) in the CSF, low serum vitamin D levels, and abnormalities on ocular coherence tomography (OCT) have all been shown to be predictors of conversion from CIS to MS independent of MRI lesion burden, some authors have more recently a
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