Melanie Cole, MS (Host): Welcome to AHN Med Talks, 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 today, we're highlighting when to suspect multiple sclerosis, a practical guide for referring clinicians.

Joining me is Dr. Troy Desai. He's the Co-Director of the Allegheny Multiple Sclerosis Treatment Center at the AHN Neuroscience Institute. Dr. Desai, thank you so much for joining us today. I'd like you to start by telling us a little bit about MS today. What do we know that maybe we didn't know 10, 20 years ago? And speak about the different types that you see very often.

Troy Desai, MD: Well, first of all, my pleasure to join you. Thank you for the opportunity. One of the changes that have come about is how we approach treatment. The old thinking was that earlier in the course of MS, people had mainly reversible changes in their nervous system. But now, we know that permanent changes can occur even early on in MS, even before people develop symptoms.

So, these irreversible changes would be things like axonal transection and loss of neuronal cells, brain atrophy. So as a result of that, the treatment paradigm is shifting more. And instead of using milder, safer medicines initially and then reacting to breakthrough disease and using stronger medicines later, more and more neurologists are using the strongest medicines from the very beginning and this is leading to better outcomes.

Melanie Cole, MS: Well, thank you for telling us about that. So when we think of which patients are likely to get MS based on demographics and symptoms, let's back up for just a minute and speak about risk factors and what you see as far as demographics for the most common risk.

Troy Desai, MD: All right. So, first of all, the prevalence of multiple sclerosis is higher than we used to think. Previously, a study from the 1970s established the number of people with MS in the US at about half a million. But within the past few years, a newer study showed that it may actually be closer to a million.

We know there's a female preponderance, almost 3:1 female-to-male ratio for multiple sclerosis. Other risk factors include tobacco use. It comes up over and over again, right, with so many medical conditions. Other ones include obesity, high sodium intake, vitamin D deficiency. Family history plays a small role as well, but most cases are sporadic, not familial. Presence of other autoimmune conditions also increases the risk of MS. And now, there's more and more evidence that environmental pollution may be playing a role.

Melanie Cole, MS: Well, that's very interesting. And do we think about things like—you mentioned genetics just briefly, but hormones, and then you mentioned environment. What are we learning about those?

Troy Desai, MD: Yeah. So, hormones do play a role. We know the incidence of pediatric MS goes up after the onset of puberty. So yes, hormones do play a role, and that also explains the female preponderance, 3:1 almost female-to-male ratio. And when menopause hits, women tend to have worsening of their symptoms, but that may be related to disrupted sleep and, you know, kind of brain fog and things like that related to menopause. Generally, as we get older, the immune system weakens and the chance of having new lesions and relapses decreases.

Melanie Cole, MS: What age are you seeing it most commonly right now, Dr. Desai?

Troy Desai, MD: Most people develop MS in their 20s and 30s, And, there's a slight delay, usually a few years delay before they're diagnosed. So, most people end up being diagnosed in their early 30s to mid-30s.

Melanie Cole, MS: So then, speak a little bit about diagnosis, because sometimes you hear stories of patients seeing many physicians and not getting diagnosed in a timely fashion. Tell us a little bit about why that happens and why it's so important to refer patients early to rule out MS, because that's what's so really important, and that's what we're discussing here today.

Troy Desai, MD: Yes. The nature of the symptoms themselves sometimes makes it difficult to diagnose. So, people may have numbness, for example. "My leg went numb and it went away in a couple of weeks, so I didn't follow up. I didn't keep my appointment. It got better. I didn't see a doctor." That's a common story. Or people may end up seeing a chiropractor or somebody else and they're misdiagnosed, "Oh, it was a pinched nerve," whereas, you know, it really wasn't. So, things like that can lead to a delay in diagnosis.

Melanie Cole, MS: Okay. Then, now the collaborative approach. When somebody does come to you, they've been referred, it's been determined what's going on. Tell us a little bit about why a multidisciplinary team is so important for these patients and what you're doing at the AHN Neuroscience Institute for the patients.

Troy Desai, MD: So, multiple sclerosis can be difficult to treat. People can have a lot of difficulties because of it. It can affect vision, sensation, strength, coordination, bowel and bladder function, cognition, mood. So many things can be affected by MS. And so, we need a collaborative approach. As neurologists, we try to treat all of those things, at least get them started on it. But sometimes our expertise is not deep enough, and so we need to refer to a psychologist or a psychiatrist or urologist for more specialized care.

When it comes to PCPs, we need to work closely with them for various reasons. Many of our medications are immunosuppressants, so people have to be educated about infection precautions and prevention. And also, they need to be vaccinated. So, we need help from primary care providers in that regard.

Also, many of our medicines are not safe in pregnancy or may not be safe in pregnancy. And this is a common condition in young women of reproductive age. So, family planning has to be considered, and we have to work with PCPs and OB-GYN for that.

So, it requires a lot of collaboration between not just physicians, but also allied health professionals such as physical therapists, occupational therapists, speech therapists.

Melanie Cole, MS: So, you mentioned PCPs, and I think that's an important aspect as we think about MS patients and all of those things that go into their treatment. You mentioned vaccination, family planning, all of these things. What would you like to say to the primary care providers that are the medical home for these patients? As the neurologist, what would you like them to know about communication with you and your team, monitoring, all of those things that you're discussing? What would you like to tell them?

Troy Desai, MD: Just what we discussed, that vaccinations are important to prevent infection. Many of our treatments are immunosuppressants. And if people are having infections, that can also flare up their old MS symptoms or their current MS symptoms. We call that a pseudo-relapse.

So if a patient calls saying, "Hey, my MS symptoms are worse," first thing we want to do is rule out an infection, either check a UA or blood count or both. So, we could definitely use help from our primary care providers for that. And we just need to collaborate on a lot of things, monitoring, safety of our medications. Some of them can be hepatotoxic or can cause various cytopenias, so they need CBC and complete metabolic panel checked six months. So, we could use help there. Sometimes patients get blood work. But we never get the results of blood work ordered by PCPs. So, it would be helpful to share that with us also.

Melanie Cole, MS: Dr. Desai, what's exciting in your field? You mentioned that you're getting more aggressive at the beginning with treatments. And so, what if a patient is refractory to some of those aggressive treatments that we used to look at as further down the pipeline, so you would start much more conservatively and then be able to progress to those aggressive treatments? When we start with those, then what's next? What's exciting that's going on in your field right now?

Troy Desai, MD: Yeah, that's a very good question. So despite our strongest, best medications, there are still some people who will have breakthrough disease. And mostly, this is in the form of secondary progression. So, relapses would be an acute change in functioning that occurs over hours or days, whereas secondary progression would be a gradual change that occurs over months or years. People complain that they're slowing down. They can't walk like they used to. Their stamina is going, their balance is going, their legs are getting weaker. These are common complaints amongst people who are having secondary progression.

Now, this secondary progression is caused by smoldering inflammation caused by immune cells that are resident within the brain. Most of our medications we have work in the peripheral circulation, and they work on lymphocytes, either deplete lymphocytes or prevent their trafficking. But most of these medicines do not work in the brain.

Now, there are some experimental therapies which are called BTK inhibitors. And hopefully, we will have one of these approved later this year. The BTK inhibitors are small molecules that can pass the blood-brain barrier and enter the brain and work on these resident immune cells that are causing smoldering inflammation, which leads to secondary progression. So, we have hope for these patients who are having secondary progression.

Right now, the best we can do is—I don't think this is going to go away. We always also have to treat their vascular risk factors. So, advise them against smoking. You know, manage diabetes, hypertension, dyslipidemia. Encourage them to be active so they can be at a healthy weight, advise them about proper diet. These things are important also for brain health, and we know people who have vascular conditions, vascular risk factors have a greater risk of progression of their MS.

Our motto is preserve your reserve. Do whatever you can to preserve your brain and that includes little or no alcohol, abstaining from tobacco, abstaining from illicit substances, living a healthy lifestyle, being physically active, being mentally active. In addition to that, we hope these new medications, BTK inhibitors will also help to prevent secondary progression or slow it down.

Melanie Cole, MS: Dr. Desai, do you have any final thoughts for referring physicians about when to suspect multiple sclerosis and a real practical guide for early referral?

Troy Desai, MD: So, young people who are having symptoms that come on rather suddenly over a few hours or a few days. But really, anybody you feel needs to have MS ruled out should be sent over. We're happy to see them. We're happy to tell people that they don't have MS if that's the case. But we certainly don't want to delay diagnosis and treatment. So, anybody you feel needs to be seen to rule out MS, we're happy to see.

Melanie Cole, MS: Thank you so much, Dr. Desai, for joining us today and telling us about what's going on in the world of MS today. And to learn more or to refer your patient, please call 844-MD-REFER, or you can visit findcare.ahn.org. Thank you so much for joining us on this edition of AHN Med Talks with the Allegheny Health Network. I'm Melanie Cole.