Melanie Cole, MS (Host): Welcome to AHN MedTalks, an informative resource for physicians across various specialties as we delve into the latest medical insights and best practices, ensuring you stay at the forefront of your field.

I'm Melanie Cole. And here to highlight the evolving landscape in MS Care is Dr. Tom Scott. He's the Co-Director of the Allegheny Health Network Multiple Sclerosis Treatment Center and a Professor of Neurology at Drexel University College of Medicine, Allegheny campus. Dr. Scott, thank you so much for joining us today. I'd like you to speak a little bit about the trends you've seen in MS, the prevalence, the average age of onset for both men and women. Speak a little bit about it, set the table for us.

Tom Scott, MD: So, I've been here at Allegheny for over 30 years and have been involved in the development of MS drug trials. And there was very little when we started this about 30 years ago. But now, we have a lot of medications. And so, the landscape has changed in terms of how we monitor patients, largely in relation to how we choose and use these immune modification drugs. We think of MS as an autoimmune disease more and more, and the medications that we have are in that realm.

Also, during the last 30 years, there has been some shifting in the basic demographics. Thirty years ago, we thought MS was 2:1 women to men. Now, it's 3:1. We used to think there was a few hundred thousand people in the United States with MS. Now, we estimate that more close to one million. MS has been diagnosed more in people in their 40s and 50s over the last decade or so. But the average age still remains in the 30s. So, some things change, some things don't change. We're learning more about how to diagnose MS early, how to look for MS early. And we're continuing to learn about how to deal with MS at all points of the arc of the disease, from a young MS patient in their 20s or 30s to an elderly MS patient in their 60s or 70s or 80s. Half of my patients at my clinic now are over the age of 65, half are under 65. So, we have quite a spectrum of disease.

Melanie Cole, MS: Thank you for that comprehensive answer. As we think about early-onset symptoms, and it used to be tougher to diagnose. What are you looking for? And you're speaking to other primary care providers what would you like them, as their patients generally end up there first so that these symptoms aren't underrecognized? Because that used to be the situation where a patient had to see many specialists to finally get diagnosed with MS. But now, there are certain red flags and markers. Speak about those.

Tom Scott, MD: Well, it's pretty unusual to have multiple sclerosis onset with a negative MRI brain. That only happens about 10% of the time when a patient is showing up with one of the classic symptoms like optic neuritis, numbness from the waist down with the mild myelitis. If that's going to be an MS case, 90% of the time the MRI scan is going to be very suggestive right off the bat.

So, for a lot of neurologic symptoms that would raise the question of MS for a primary care doctor, such as numbness, weakness, vision problems, especially in younger patients, I think I've seen PCPs have a lower threshold for ordering MRI scans over time, which has been appropriate. And some of these patients are obviously going to go on to a specialist, even with a negative MRI scan of the brain. But with that negative MRI scan of the brain, we can be reassured that most of those people aren't going to have MS. Primary care doctors should also be aware that a lot of patients have so-called nonspecific white matter abnormalities on MRI scan, and that really is going to have to go to a specialist to get figured out.

And some people consider the changes of MS in themselves to be nonspecific on MRI, but there are some classic appearance for MRIs with very rounded lesions, what we call ovoid lesions in the range of 4 to 10 millimeters, sometimes oriented away from the ventricles or abutting the ventricles that are very typical for MS. And a lot of radiologists will make that call and say, "I really think this is typical of MS." So, MRI scan has really changed the diagnosis of early MS going way back.

I think the newest thing that we're talking about a lot of is the so-called prodrome of MS, which we've identified better in the last five years. And by that, I mean very nonspecific symptoms of MS, fatigue, depression, patients going to their doctors with aches and pains and just general malaise and fatigue and maybe poor endurance. It's harder to know whether or not to order an MRI scan on patients with these prodromes. We can't MRI everybody with every symptom, but it's interesting to note that when we do make that diagnosis of MS in a patient with optic neuritis, we can often retrospect that prodrome that's been going on for a few years.

Melanie Cole, MS: I'd like you to speak about how personalized treatment approaches have impacted MS care in recent years, starting with interventions in younger patients and moving on to the differences if the patient is more senior. As you said, you've even got patients over 65. Give us a little bit of an overview of some of the recent advancements in your field that are really exciting.

Tom Scott, MD: Well, it's exciting that we have so many choices now. It's exciting that we can offer patients so many different types of treatments and it's very personalized. And we use what we call shared decision-making when we choose, for instance, that first drug of MS or changing drugs because now we've got a side effect or breakthrough disease. Anytime we choose a drug in MS, we use a lot of shared decision-making.

That being said, one of the reasons that this situation is so complicated is we take into account patients' preferences in terms of their psychological approach to treating a chronic disease with medications that have known side effects and allowing patients to express how do they feel about risk of side effects versus efficacy of a medicine over a period of many years. And this might include also route of administration, how do they feel about pills versus shots versus infusions, and various side effects associated even with route of administration. So, some patients, for instance, want to have a very effective medicine and are willing to tolerate more risk, primarily of infection when we're talking about immunosuppressive drugs or other risks, whereas other patients are mostly concerned with safety, they have medication fears, they don't want to start off on medication at the highest level of efficacy when they have an option to start at the highest level of safety and use so-called escalation therapy as needed depending on signs of breakthrough disease by MRI or clinical.

So at Allegheny, we're involved with a study now, which we share with Johns Hopkins and many other large MS centers, where because there's really no right answer for the first drug, patients also have opportunity to contribute to research by volunteering to have a randomized choice of medication, somewhat depending on their presenting symptoms, but also dependent on how things go over time. A computer would actually randomize them into one arm or another, very similar to the American Cancer Society-sponsored trials of cancer protocols which are spread across many centers.

So in the future, we'll have more information looking back on this. It's a prospective study. But as we go forward, most patients actually do not choose to go into that study. They choose to have a shared decision-making with their physician, and choosing their first drug. Then, on the late end of the spectrum in elderly patients, our primary considerations are when to come off drugs, because the medications are probably not needed in most patients after age 60 or 65 as the disease starts to burn itself out. And certainly, there's a different discussion of risk-benefit of these medicines in elderly patients who have a higher risk of infection.

Melanie Cole, MS: Tell us a little bit about some of the advancements such as immunotherapy and those strategies and how they're utilized in that shared decision-making.

Tom Scott, MD: We basically divide our treatments into two buckets. Immunotherapy, which is all about preventing new inflammation or new problems and symptomatic therapy, which might be aimed at leftovers, let's call them from old problems, such as spasticity, bladder problems, depression, cognitive issues, things that patients deal with over many years of evolving multiple sclerosis.

So, looking first at immunotherapies, that's basically what I was talking about in the question before. We explain to patients that we think of MS primarily as an autoimmune disease. We want to slow down the overactive aspects of your immune system, which are reacting against your own tissues, primarily looking at activities of white blood cells, and we explain to them how autoimmunity works in MS might compare it to rheumatoid arthritis. And tell them in rheumatoid arthritis autoimmunity, white blood cells attack your joints. In MS, it's limited to the spinal cord and brain and optic nerve. And using that kind of explanation, we explain to some extent what the drugs do to rein in these overactive white blood cells, and we can even go into more details, talk about T cells, talk about B cells. And then, we talk about interactions with other possible medications, and we go from there.

Melanie Cole, MS: Doctor, as you're telling us about these advancements in the shared decision-making, one of the things that is really important for MS patients and people living with MS is this multidisciplinary approach. Can you speak about how that collaboration has improved outcomes for MS patients and who all you work with on your team?

Tom Scott, MD: Well, it certainly is a team approach and even a community approach. On our team, we always involve an MS nurse who's experienced in answering questions that come up. They could range from diet to exercise to side effects from drugs, administration of drug issues, obtaining drugs in the complex market of health insurance. And so, the MS nurse is important on the team and a resource for our patients. But, you know, we always tell patients, if you really feel more comfortable asking a doctor rather than a nurse about a particular question, you can go straight to the nurse, straight to the doctor, you don't have to stop at the nursing level. But the nurses can be very good at reinforcing education the same way the physician is. And we can complement each other. So, the nurse is very important, I think, for education, managing day to day decision-making, and triaging phone calls and communications in the electronic medical record system.

Then, we have a physical therapy team that we don't always have to use. Many of our MS patients really have no disability needing any physical therapy, but many do. And there's a wide range of aspects of physical therapy which might be employed all the way up to bracing and assistive devices if needed. Many of our patients do not need assistive devices, but many do. So, we work closely with physical therapy, occupational therapy.

Similarly, we work closely with the PCP giving feedback on management of generalized symptoms such as fatigue and looking at the overall health aspects of patients in terms of being a good health coach along with the PCP. We know that managing comorbidities, diabetes, hypertension is important to the overall outcomes in MS. We want to work with the PCP to manage things like fatigue, depression, and anxiety. So, the PCP is an important member of the team.

Then, we have the research community here at Allegheny, which helps us offer patients an extra opportunity if they would like to participate in trials. And then, community-wide, we work with the National MS Society and other societies to help connect patients with other patients with MS, families with MS, help manage issues related to caregiving. So, it's quite a big team. We might work with ophthalmologists, we might work with an ear doctor, we might work with a radiologist, just to mention a few of the ancillary people we might work with depending on the patient's problems.

Melanie Cole, MS: Very comprehensive approach as we wrap up. Doctor, please tell us something new, anything exciting that you'd like to speak about, and some future directions in multiple sclerosis care, what you hope to see happen and what you do foresee happening.

Tom Scott, MD: Well, I think we've really made a ton of progress. The percentage of patients that achieve disability with MS is completely flipped from where it was 30 years ago when most patients were disabled by age 50 or 60. Now, very few are, a much smaller percentage are. And we're seeing that number of disabled patients going down decade by decade, so that's exciting to watch.

As part of that, not only improving our drug therapy, we're improving our monitoring to know when we need to change drugs. Certainly, we would like to have new drugs that tackle somewhat the aging process of MS that may have implications in neurology, not just in MS, but across the board in so-called degenerative diseases that we would like people to age better. That's a tough nut to crack, but we're working on it. And we're working on monitoring that with MRI scanning so that we can distinguish different types of problems over time better.

Right now, we're very good at picking up new inflammation by MRI. We're not very good at picking up degeneration, but we have some ideas about how to do that soon. And we also are working on blood markers so that maybe you don't have to go to an MRI scan. Maybe we can do a blood test and tell us a lot about the health of your brain and your brain cells by measuring certain brain proteins. And we think we're getting close to being able to do at least some of that within the next few years.

Melanie Cole, MS: What an exciting time in your field, Dr. Scott. Thank you so much for joining us today and sharing your incredible expertise on multiple sclerosis and the Center at Allegheny Health Network. To learn more or to refer a patient, please call 844-MD-REFER or you can visit ahn.org. Thank you so much for joining us on this edition of AHN MedTalks with the Allegheny Health Network. Please remember to subscribe, rate, and review this podcast and all the other AHN MedTalks podcasts. I'm Melanie Cole. Thanks so much for joining us today.