The Best and Worst of Times?

“It was the best of times. It was the worst of times.” Dickens' paradox might well apply to the current state of MS therapeutics. On the one hand, it is becoming easier to diagnose persons with MS at an early stage. After diagnosis, clinicians and patients together may choose from more than a dozen disease-modifying therapies (DMTs) when not so long ago there were none. There are also myriad strategies for symptomatic management.

On the other hand, this therapeutic armamentarium comes with its own set of challenges. Choosing the so-called best DMT for an individual patient is complicated and nuanced. Vigilance is required in monitoring both side effects and efficacy of treatment for each individual. Although diagnosis is easier, there is still no single definitive test for a diagnosis of MS and, current prognostic indicators are limited in accuracy.

In this issue we are privileged to have a veritable who's who of the field as authors, and they have provided a practical review of current guidelines and state-of-the-art practices.

Dr. Alexander Rae-Grant and Dr. Kedar Mahajan give a practical and comprehensive summary of the recent AAN guidelines for disease-modifying treatment of patients with relapsing MS—a valuable resource for practitioners as they partner with patients to choose or change a DMT.

Drs. Aaron Carlson and Lawrence Steinman have written an elegant introduction to the newest DMTs, the monoclonal antibodies (MAbs), and provide tantalizing information about new MAbs in development.

Drs. Edward Fox, Esther Melamed, and Elliott Frohman contribute a patient-centric approach to diagnosis and prognosis; their combined clinical expertise will be helpful to and resonate with clinicians.

Although there is currently only 1 FDA-approved DMT for progressive MS, Dr. Charles Smith masterfully describes additional strategies that can be employed to alleviate symptoms and improve function and quality of life.

Fatigue is among the most common and least well understood symptoms of MS, and Dr. Jonathan Carter provides a clear and detailed explanation of primary and secondary fatigue as well as treatment options. Dr. Tiffany Braley has provided a comprehensive and thoughtful introduction to understanding and managing sleep disorders in persons with MS, another common but often under-recognized and undertreated comorbidity. Other commonly under-recognized and undertreated symptoms of cognitive dysfunction and mental health issues may affect at least 50% of persons with MS, and Drs. Kathleen Tingus, Katelyn Steele, and Alexander Steiner guide us through diagnosis and treatments for these often-devastating impairments.

Most persons with MS are young women in their reproductive years, and thus every practitioner who treats persons with MS should be able to discuss the impact of MS on reproduction and, conversely, reproductive issues that may impact MS. Dr. Patricia Coyle, one of the most widely recognized experts in this area, highlights current information and best practices regarding pregnancy, contraception, and menopause and how these affect people with MS and MS therapeutics.

Dr. Ilya Kister shares his own MS Lesion Checklist for avoiding misdiagnosis of MS based on MRI findings, which we expect to be very useful in practice, as imaging is not always straightforward in this regard.

The use of integrative medicine is much higher among persons with MS than in the general population. Dr. Allen Bowling, perhaps the foremost authority on integrative medicine and MS, guides us through the most commonly used and asked about nonconventional treatment options and also discusses the importance of lifestyle in MS care.

There is never a good time to be diagnosed with MS, but we hope that the information in this issue will help practitioners share with their patients that this is the most hopeful time for them to live their best lives with this disease. We welcome your comments.