Jaime Lewis (Host): The landscape of multiple sclerosis treatment has evolved dramatically in recent years, offering new hope and options for patients. From disease-modifying therapies that can slow progression to innovative approaches on the horizon, there's more reason for optimism than ever before.

Here to guide us through the current treatment landscape and what's coming next is Dr. Ann Cabot, a neurologist with Elliot Health System who stays at the forefront of MS treatment advances.

This is Elliot Health Talks. I'm your host, Jamie Lewis. Dr. Cabot, welcome back to the program.

Dr. Ann Cabot: Thanks. Great to be here.

Host: Let's start with the big picture. What treatment options are available for MS patients right now?

Dr. Ann Cabot: Well, we're really blessed. I think you have to take this and look at it in the context of what's been available over the years. We actually didn't have any MS therapy that was FDA approved until 1993. And those were interferons. So, those are injectable therapies. Patients would take a variety of different shots, either every other day, once a week. They did help slow disability progression and decrease relapse rates, but not as effectively as we would like. And so, while there was some progress made, it really was challenging for patients. You know, these drugs had side effects and overall were quite safe. But, you know, we had to do blood tests and monitoring, and they had to give themselves injections very frequently. So, there were injection site issues, a bit annoying. And again, they didn't really shut all the disease down for a lot of folks. So, that was sort of the early course for a number of years.

Prior to that, patients were getting sort of a whole host of different non-approved therapies, and a lot of steroids. So then, we had the development of additional therapies over the years, and these have really changed the landscape. So if we think about it in terms of time, we have had Copaxone, which is another injectable therapy, and then an infusion therapy called Tysabri, which came along initially. So, patients would get an infusion once a month with this medication, and it was highly effective, but unfortunately did have some risk. So, that was important to review with patients.

And, you know, it's always important to review risk and benefit. When a patient and a provider are talking, what we're doing is trying to say, "Okay. Here's the med. Here's what it does. Here's what we hope it does for you. What are we trying to treat? We're trying to slow down relapses. We're trying to prevent new lesions on your brain MRI. And we're trying to slow down progression." That's our goal for all the treatments. But what risk does each medicine have? And each medicine has a different risk and each category of medicine attacks the immune system in different ways, right? So, to try to prevent the MS from ongoing. So then, since that time now we have over 20 therapies for MS, which it makes for long appointments to go over these therapies, but they're pretty tremendous.

Host: I've heard of disease-modifying therapies, DMTs. Can you explain what those are and how they work?

Dr. Ann Cabot: Yeah. So, MS, it's a chronic, lifelong autoimmune demyelinating disease of the central nervous system. And when we say chronic, it means like other conditions, once you get diagnosed, you have it for life. We don't have a cure. So, we are going to be sort of monitoring you and treating you for the long term. That's the hope.

So, disease-modifying, when I think of it that way, I think, "Okay, so how can we take this disease that we're living with and make it so it stops attacking myself?" How can I get this immune system to say, "Calm down. Don't cause a new lesion. Don't attack yourself," all that stuff. So when we're modifying, that's what we're really doing. The drugs are geared in different ways to decrease those three main aspects of MS.

Host: Okay. Well, once somebody starts any of these treatments, how do you track whether it's working over time?

Dr. Ann Cabot: It's really one of the most important things. So especially when we use some of our earlier therapies that weren't quite as effective, it was really important to have the patient make sure they understood to contact the office if they were having new symptoms. So most common, if they had new numbness or tingling or weakness, new vision changes, new bladder-bowel symptoms, really important to let us know.

Routine imaging is really helpful. So, the imaging we use is MRI scan. So usually, we'll get updated imaging. And the reason to get imaging, even if a patient isn't symptomatic, is to look for silent progression of disease, meaning they might have new lesions that they didn't feel. It wasn't in an eloquent area. So, that imaging is really helpful. It's very objective as well, because sometimes people may feel unwell and we're not sure if it's MS or something else. So, that's also very helpful in that regard. So, that imaging is another way to determine and then getting the patient back in the office for repeat exams routinely to make sure things haven't changed with regard to the physical exam.

Host: Well, can MS go into remission? And if it can, how does treatment support that possibility? Are they hand in hand and how so?

Dr. Ann Cabot: Yeah. So when you think of our most common type of MS, it's relapsing-remitting MS. So relapsing-remitting MS, 85% of our patients are diagnosed with that form of disease. And our hope is when we treat patients, that we won't see more relapses. So especially if they're treated, you may never have another relapse. So technically, you'd be in remission.

Now, even in the natural history of the disease without treating it, people have a huge variety of time in between relapses. Some people may have a relapse. Two months later, they may not have a relapse for two years. It's a very unpredictable disease, which makes it really challenging.

The other thing is you can have silent progression of your disease, meaning changes on the MRI without really feeling it. So, that can be very subtle and lead to longer term progression in the long run. So, that's another reason we want patients to be treated, because there are many studies that show treating relapsing forms of MS, patients have far better outcomes than not treating, especially early on in the course of the disease. So over these years where we've had all these therapies, we've also learned a lot about which therapies are higher efficacy than others, what side effects they have, what risk they have, who's a good candidate for what therapy?

And I think the other important thing is to really consider how your biology changes as you age and putting yourself in there. You know, as we age, we tend to get more infections, so we have to be very aware of that when we're immunosuppressing our patients. As people age, they also acquire other medical conditions like hypertension or diabetes, you know, so we want to make sure we're aware of those features of their habit as well. And then, also make sure our patients are educated as to what disease-modifying therapies are out there, because there are so many. It's really challenging, but also really a fun part of the job.

Host: Well, looking ahead, speaking of fun parts of the job, are there any new or experimental treatments coming down the pipeline that have you excited?

Dr. Ann Cabot: I mentioned that right now we have so many therapies, so I can just briefly go over what we already have. I kind of didn't complete it, I apologize. But we have a whole class of oral therapies called sphingosine modulators. There's four of those. We have the fumarates, they're also oral medicines, and a teriflunomide. So, all of these, they work a little differently on the immune system, and they've been very nice. Because if one therapy doesn't work for a patient, we can always pivot and go to a different class, and that's been really handy.

The B-cell therapies have really been a game-changer for a lot of our patients. There are three B-cell therapies available. Two are infusions and one is a self-injection and they have very high efficacy, generally very well-tolerated. We do have to talk to patients about the immunosuppression part and how we monitor that. But this has been an enormous breakthrough for patients with MS. So, that's been really a groundbreaking thing for a lot of us. And then, we have another one called Mavenclad, which is a reconstitution therapy. So, so many, right? These are all outlined. We sit down with a patient, we choose them together. That's a really big part of our job.

And then, there's websites that we use to educate patients, because there's so much to learn. You can go to the MS Society or the MSAA Ultimate Treatment Guide, and that will walk you through sort of some of these different options. And then, we meet with the patient again to pick one ultimately. If the patient's had MS for 20 years, they may start on one therapy and have been on a few others over the course because maybe tolerability issues. Don't forget. You may try a therapy and you don't like it, it doesn't agree with you, maybe it causes a side effect you don't like, or you had an infection, we have to move on to something else, right?

And then, we have new classes of medications coming out. Really, the unmet need for MS right now is progression of disease without relapses, so the less inflammatory part of the disease and the more progressive part of the disease, which is really hard, because it happens as we age. You know, as we age, we drop out neurons. And so, if you already have underlying disease, it makes it harder to compensate. So, this is really where a lot of the research is going.

And the newest category of drugs that probably look very optimistic for us, although I always say that there will be risks and benefits we have to juggle, are the BTK inhibitors. So, we're looking forward to seeing if those will be FDA approved in the near future.

Host: Dr. Cabot, thanks so much for sharing this comprehensive look an exhaustive look at the current MS treatment options.

Dr. Ann Cabot: You bet.

Host: That was Dr. Ann Cabot, a neurologist at Elliot Health System. To explore treatment options and learn more about MS Care at Elliot Health System, visit elliothospital.org and search neurological specialties. If you found this episode valuable, please share it with others who might benefit from this information. And thanks for listening.