Navigating Multiple Sclerosis Disease-Modifying Therapy

Multiple sclerosis (MS) is a chronic disease of the central nervous system characterized by inflammation, demyelination, and degenerative changes. It affects about a million people in the US and is a leading cause of disability in young people. Great advances have been made in the development of disease-modifying therapies (DMTs) since the first MS-specific medication came on the market in 1993. Multiple medications with distinct mechanisms of action are now approved, which have demonstrated a reduction in number of relapses and radiographic disease activity and a delay in disability progression. As these treatments have become available, however, choosing and monitoring DMTs has become more complex. This issue of Practical Neurology is bringing you several articles from experts in the field to address important questions surrounding DMT use in MS.

Bruton Tyrosine Kinase Inhibition in Multiple Sclerosisexplores a new class of DMTs currently under investigation for MS with several medications in this class of drugs appearing close to gaining approval. BTK inhibitors may add another option with a different mechanism of action, and the article puts these therapeutics in the context of their immunologic mechanism of action and explores their potential usefulness in both relapsing and progressive MS.

Because there are now more DMT options, it is important to understand how best to tailor DMT decisions to individuals with MS. In Treating Early Relapsing Multiple Sclerosis: Induction & Escalation Approachesthe authors describe the different approaches in deciding on a DMT in early relapsing MS. Treatment optimization is especially challenging because MS is a highly heterogeneous disease with a wide range of presentations, disease courses, and treatment responses. In Prognostic Factors in Multiple Sclerosisthe authors delineate which demographic factors, clinical features, and imaging findings are associated with an increased risk of highly active disease and rapid disability accumulation, which is crucial to improving clinically outcomes. On the flip side, Discontinuing Disease-Modifying Therapies in Multiple Sclerosisreviews the question of when it may be safe or even advisable to consider stopping DMTs. The authors describe that there may come a point where the risks of DMTs outweigh the benefits.

Risks are an important aspect of decision making regarding DMTs, and infections are a common risk to consider, especially for higher efficacy medications. COVID-19, Vaccinations & Multiple Sclerosis provides an update about an infection that is foremost on many peoples’ minds at present and its intersection with MS. The authors discuss how MS and its DMTs may affect risk of COVID-19 infection and response to COVID-19 vaccination.

In Managing Uncertainty in Multiple Sclerosis, the challenge of tolerating the uncertainty that comes with the diagnosis of MS is discussed. The paper describes how MS creates a constant uncertainty-driven challenge that can affect function and quality of live and gives an overview over psychotherapeutic interventions. The author also provides practical considerations for physicians and the healthcare team as they interact with patients with MS and help them navigate the uncertainty associated with the disease. These considerations can be helpful not only at diagnosis but also when facing decisions around starting, stopping, and changing DMT.

I thank the authors for their time and expertise in putting together these papers, and I hope the multifaceted articles can spur reflections about how we approach MS and its treatment. The world of DMTs in MS is gaining tools, and we are hopefully moving to a more personalized care. This holds many promises for the future but can also make decisions more challenging for patients and those who care for them.