The changing landscape of MS: A neurologist’s point of view
Article from Autumn 2020 edition of Intouch Magazine

The past two decades have seen changes to the MS landscape which have dramatically altered the prognosis of people with relapsing-remitting MS. We spoke to two neurologists to find out their opinions on how an MS prognosis has changed over the past 20 years and indeed, what it means to be diagnosed with MS now in comparison to 20 years ago.

OlgaDoctor Olga Skibina MBBS, MD, FRACP, Neurologist

From your point of view, how has the trajectory of MS changed for patients over the past 20 years?
It’s been a really dramatic change. At the beginning of the century, we had four medications. Now, we have 14 and these medications are three to four times more efficacious, and that has changed not only the MS landscape but also the outlook and expectations of newly diagnosed patients from the point of view of disability progression. 

Have we seen advances in the way MS is treated which have a positive impact on a patient’s prognosis?
Yes absolutely. We now know that treated relapsing-remitting MS is less likely to evolve into secondary progressive disease. This is already proven, and we have research data, that people who go into early treatment (within the first three years) are less likely to develop progressive stage of the disease. When we look at the data, we see that when we compare our current cohort of patients who have been treated for at least 10 or 11 years to historical cohorts (not treated), they’re healthier, they have less disability and their trajectories to develop disability have changed significantly. They stay employed and they have accumulated much less disability and they’re expected to accumulate much less disability later in life, say 25 to 30 years down the track. And we’re now seeing much fewer disabled people in our waiting rooms compared to the year 2000. It has changed, and it’s an observation not only in Australia but around the world.

What about for people with progressive MS?
With respect to primary progressive, we don’t have as much of a positive outlook as yet. We only have two therapeuticals: (Ocrelizumab) and Biotin (vitamin B7), only Ocrelizumab is approved for treatment of progressive MS but not PBS listed. We wish to treat people with progressive MS from the onset, and we’d like to have more therapeuticals, as preliminary data tells us that the treatment has beneficial effect by slowing down the trajectory of progression. 

Is there anything that is now known that can improve outcomes for a person with MS?
Many things, and researchers and doctors continue working on these tirelessly. Firstly, we want to treat all patients. The majority of people with MS (more than 95% of patients) do benefit from treatment. We’ve demonstrated in multiple studies that treated patients have less disability when compared to patients who receive no treatment, they are more likely to remain employed and have better brain volume, therefore treatment protects their brain from volume loss (atrophy). Studies also demonstrated that having a healthy lifestyle, healthy weight, taking regular exercise, having a healthy diet, taking vitamin D supplements and not smoking dramatically improves outcomes. The healthier you are, the better you will do MS-wise. 

Has the new millennium seen any advances which have a positive impact on a patient’s prognosis? 
Yes. First of all, we are much quicker to identify a patient who will need more aggressive therapy and we are much swifter in moving towards highly effective therapy. Therefore, we give these patients a better chance at having a better outcome. We have also identified the need for brain health – various lifestyle issues. We are also addressing patients’ mood problems and treat those earlier because depression and mood disorders negatively impact on long-term prognosis. Treating comorbidity is also incredibly important and will also help to achieve better results. Allowing patients access to physiotherapists and dieticians will further improve their prognosis. All these elements of patient care are very important and allow patients to have much better outcomes. 

AnnekeAssociate Professor Anneke Van der Walt, Neurologist 

Does a person diagnosed with MS today have a better prognosis than a person diagnosed 20 years ago?
Yes, people with MS have a better prognosis for several reasons.  First, is the realisation that early effective treatment can make a big difference in outcome. In some cases, we observe prolonged “remissions” of the disease where there is no evidence or minimal evidence of any disease activity for years. As for survival, whilst it is true that long-term studies have defined a slight decrease in life expectancy for people with MS, this by no means holds as true in the current treatment era.  It is quite possible and to be expected that should survival studies be done now or in a decade, after widespread use of highly effective disease modifying treatments, that we would see a different result. 

Is the scientific community’s understanding of the roles of genetics and immunology in MS causation different now to what it was 20 years ago?
Numerous genetic variations have now been discovered that can increase a person’s risk to develop MS.  However, the most important genetic factor, carriage of HLA-DR2 B15*01 has remained unchanged.  The genetic variations discovered so far can also only partly explain why someone with MS develops the disease and the impact of environmental risk factors still plays a critical, although not fully understood, role in disease development. 

Given the rise in popularity of alternative therapies as complementary treatment options for neurological conditions, do you think that these will play a more important role in the treatment of MS symptoms in the future?
It is hard to know what role complementary treatments will play in future.  At the moment, the best evidence for supplementation exists for vitamin D. In contrast, large population studies have shown that supplementation with omega-3 fatty acids and fish oil plays no role in MS disease progression.  Supplements that may be useful in progressive MS are Biotin or vit B7 and possibly alpha-lipoic acid that is found in flaxseed oil. However, many people with MS find benefits in different supplements on the individual level and this is generally not harmful. In my opinion, exercise and investing money spent on numerous supplements in a trainer or exercise physiologist may be of more benefit in the long term. 

Currently most treatments are for relapsing-remitting MS because this is the most common form of MS. Do you think that the future will look at also treating other types of MS?
There are currently many exciting agents in development that may protect or reverse damage to the brain and spinal cord from MS.  This is of course very exciting!  However, new drug development and testing can take years. The same is true for progressive forms of MS where a huge research effort is underway to develop new treatments. I think it is very likely that we will see some exciting breakthroughs over the next few years for progressive MS.  In the future, I think that people with MS are likely to be on two therapies – one to suppress and manage inflammation and hopefully, a treatment to protect and repair the nervous system. 

Moving forward, how do you see the role of Paediatric MS research and clinical trials in providing insights that adult MS research doesn’t?
MS is an interesting disease in that people’s prognosis is often better when they develop the disease at a younger age.  This is thought to be due to the brain’s ability to repair and adapt to injuries. Paediatric MS teaches us that the brain can repair and recover and highlights how much this is dependent on the health and state of the brain when the injury occurs. This has led to an emphasis on overall brain health as people age – that means a healthy lifestyle, keep your brain active, a healthy diet and managing all other medical problems (such as for example high blood pressure) well. 

Researchers also speculate that a combination of genetic and environmental factors are at play in MS causation, but it’s not fully understood how. Given this current situation, what do you think the future look like for MS patients?
The interaction between genetics and the environment is a very exciting research field. I think we are getting closer to understanding these interactions and therefore developing a way even to prevent MS.  A good example would be the push to develop a EBV (Epstein Bar virus) vaccine.

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