Rania Habib, MD, DDS (Host): ​The National MS Society estimates that 1 million Americans are currently living with multiple sclerosis, nicknamed MS, and these patients are living longer thanks to advancements in symptom management. In this episode of Maimo MedTalks, we explore MS diagnosis, testing, and treatment options.

This is Maimo MedTalk. I'm your host, Dr. Rania Habib. Joining me today is MS Certified Nurse Practitioner, Anne Ocello, and Neurologist Jamie Nichols, who is the Director of the Maimonides MS Care Center. They are here to discuss multiple sclerosis diagnosis, symptoms, and testing. Welcome to the podcast, Anne and Dr. Nichols. We're so honored to have both of you here with us today.

Anne Ocello, NP (Guest): That's great to be here.

Jamie Nichols, MD (Guest): Thank you.

Host: Now let's just jump right into it. Dr. Nichols, what is multiple sclerosis?

Jamie Nichols, MD (Guest): Multiple sclerosis is considered to be an autoimmune disease of the central nervous system, meaning the person's immune system causes unwanted inflammation in the optic nerves, the brain, or the spinal cord. Like other autoimmune diseases, it tends to present in early adulthood. And it is a chronic disease causing inflammation again in the brain or spinal cord that may result in the manifestation of neurologic symptoms.

Host: Thank you for that very detailed description. Now Anne, we understand that there are several subtypes of multiple sclerosis. Could you describe them to us for us?

Anne Ocello, NP (Guest): Yes currently there are four different types or subtypes of MS. The first one being clinically isolated syndrome. This would be the first clinical attack of MS. The second one is relapsing remitting, MS. This is the most common type of MS, affecting about 85 percent of diagnosed cases of MS and is characterized by flares or attacks, then recovery.

A third type is called secondary progressive, and a fourth type is primary progressive. We use this as a guide to estimate the course of the disease state but it's, we don't put someone in a box. Sometimes it takes time to understand where a person is in the disease.

Host: Okay. That makes a lot of sense. Now, Dr. Nichols, how does a patient present with multiple sclerosis? What are the actual signs and symptoms of this disease?

Jamie Nichols, MD (Guest): Sure. I'll start off by saying that if one were to Google the symptoms of MS, I think a lot of people might look at the list of symptoms and say, oh my gosh, do I have to see a neurologist? Because there are symptoms like fatigue. Headaches, blurry vision, numbness or tingling, a lot of things that can be a little more nonspecific, maybe symptoms that can be present from a number of different disease states.

So specifically, as a neurologist, what really perks our ears to, to a possible diagnosis of MS are signs and symptoms of classic clinical syndromes. So one of those, for example, would be an optic neuritis. So again, MS affects the central nervous system. That's the optic nerves, the brain and the spinal cord.

If there's inflammation of an optic nerve, the nerve behind the eye, a patient would classically present with the onset over days of pain with eye movements, and then over days to weeks, blurry vision of the affected eye and decreased color vision of that eye. Alternatively, if inflammation occurs, in the brainstem of the brain, a person might present with vertigo or a sensation of spinning or movement.

They might present with double vision. And if there's inflammation in the spinal cord, which carries all the motor and sensory information for our limbs; a person might develop, again over days to weeks episodes of extremity numbness or tingling, or weakness. Can also affect the bladder and bowel and cause symptoms such as urinary urgency, frequency, or retention.

Host: Okay. Thank you for that very detailed description of all these signs and symptoms and I can see what you're saying that if the layperson just decides to go to Google, everyone might think they have it if they have some of these symptoms. Anne, how is multiple sclerosis diagnosed?

Anne Ocello, NP (Guest): It is diagnosed using criteria called the McDonald's criteria. This looks at patient history or a history of events and symptoms, MRI findings. Sometimes we need additional information like a lumbar puncture. There's no simple blood test to detect multiple sclerosis and sometimes it takes a little bit of time to collect all of the data to fit the criteria. Everybody's a little bit different.

Host: Now, Anne when patients are suspicious that they have it, are they supposed to go to their primary care right away or a neurologist right away? How does that work?

Anne Ocello, NP (Guest): So sometimes the primary care doctor is the first stop in the health journey. Sometimes it could be the emergency room, but a neurologist is really key in finding the right diagnosis because there are other disease states that can look like MS or behave like MS, so it's important to rule those out.

Host: Okay. Now, Dr. Nichols, once a patient meets this criteria and we have a high suspicion that they have multiple sclerosis, what type of testing should a patient expect to undergo to confirm a diagnosis of MS?

Jamie Nichols, MD (Guest): Sure, as Anne alluded to, we make the diagnosis of MS based on diagnostic criteria because you know, as a field, we haven't yet isolated the exact immune protein that is the catalyst for this inflammation. So, what we don't, again, so we don't have a test to be able to say yes, you have it or no, you don't. The criteria we use are based on clinical symptoms, so again, a person with a history in the past or a current history of symptoms that are consistent with a classic MS syndrome, again, such as an optic neuritis and also findings on the MRI.

A lesion on an MRI is just a white spot that we see on the MRI. It doesn't tell us what the underlying cause is. So, as neurologists, we have to look at the size of the lesions or the spots, the shape of them, the pattern, the location, how many of them there are, and that can also really help with a diagnosis.

If we can prove, based on a patient's symptoms and MRI findings, that they fulfill the McDonald Criteria for a diagnosis; then we'll make the diagnosis. If someone doesn't quite fulfill criteria, but we have a high clinical suspicion for MS, we might do a lumbar puncture or a spinal tap and look for inflammatory markers in the spinal fluid.

 And while that is not something that is completely specific to multiple sclerosis, there is a pattern of inflammatory markers in the spinal fluid that is seen in upwards to 95 percent of people with MS. So if we have additional clinical and MRI evidence, and also these findings in the spinal fluid that can be enough to tip the scales and say, you know what, we are going to treat this as multiple sclerosis.

Host: Okay.

Jamie Nichols, MD (Guest): And I will also add in terms of testing, you know, during a diagnostic workup, a key feature of the diagnosis is that there's no better explanation. So there are a number of either autoimmune diseases like lupus that can affect any organ system in the body, including the brain and spinal cord. And there are other neurologic diseases that might cause symptoms or lesions on the MRI scan that look similar to MS. So during the diagnostic workup, there may be additional, for example, blood tests that we do to rule out any other potential causes.

Host: Okay. Dr. Nichols, so once we have undergone this testing and they meet the criteria, now we are pretty positive that they have MS and we're ready to go on to treatment. How is MS actually treated?

Jamie Nichols, MD (Guest): So the treatments we use for MS, we refer to them as DMTs, which stands for disease modifying therapies. And today, you know, as of 2024, there are upwards to, over 20 different treatments for MS. Which is really exciting because 10, 20 years ago, there were maybe either zero or only a couple options.

So now that there are a number of different treatments, we can have a real personalized discussion with the patient to discuss an approach to treatment, different options, whether that is route of administration, such as injection or an oral pill or an infusion, the mechanism of the disease modifying therapy, which is either going to be immunomodulating, so modifying the immune system, but not necessarily suppressing the immune system, or some of the therapies are, in fact, a bit immunosuppressive.

Because again, as an autoimmune disease, we're dealing with an immune system that's a little bit too active. So we want to quiet down the immune system, whether that's by suppressing the immune system or modulating it. And we have enough treatments that we can, really have a shared decision making process with the patient and they can choose what's really best for them and what fits with their lifestyle.

Host: Okay. And how well are these treatments tolerated, Dr. Nichols?

Jamie Nichols, MD (Guest): It depends on which medication we're talking about. So the older treatments, like Copaxone, we sometimes still use, is an injection. Some people don't like to give themselves injections a few times a week, but overall if someone can deal with that, there are really no other side effects. Some of the oral medications, like Tecfidera, which is a class of medications called the fumarates might cause some GI upset at the beginning or some flushing, but overall are well tolerated.

There's a class of medications, the S1P modulators, that tend to be very well tolerated. And then there are infusions, such as Tysabri. It's a once monthly infusion, which may not work for someone's lifestyle. But overall has not many other side effects. And there are the B style therapies, like rituximab, historically, but now Ocrevus or Kesimpta which are either infusions or sub Q injections, which run the risk of increasing risk of infection because they're a little immunosuppressive.

But again, other than the infusions or the injections themselves, are extremely well tolerated.

Host: That's fantastic. That's great news for these patients. Now, Anne, in our introduction, we know that the National MS Society has shown that patients are living much longer with MS. So a question that I'm sure patients want to know is, is MS curable?

Anne Ocello, NP (Guest): Unfortunately, it is not curable at this time. Hopefully in the future, there will be some treatment to reverse it or put it into remission indefinitely. But currently we have treatments to slow the disease progression, preserve function, and prevent relapses which allows a person to live a long, healthy life with good function.

Really the key is to detect early, treat early, and follow a person through their lifespan with this disease, monitor them and try to keep them as healthy as possible.

Host: Absolutely. Now, Dr. Nichols, Anne said MS is not curable. Are there any promising MS treatments or research on the horizon?

Jamie Nichols, MD (Guest): Absolutely. And this is one of the reasons that I was so excited to go into this field in the first place. The field of neuroimmunology and multiple sclerosis is currently a fast paced, a fast moving field in terms of research and new treatments. So we mentioned that there are, there are numbers of different therapies that may be part of the same class of medications.

For example, the B cell therapies, our prototype for that is, rituximab. But in recent years, we've improved upon or modified it a little so that now we have different options within the same class of medication. So for the B cell therapies, there's rituximab, there's now Ocrevus, which is specifically approved for MS. These are both infusions given once every six months. After Ocrevus they approved a B cell therapy called Kesimpta, which is a sub Q injection.

So, in one aspect, there seem to be constantly new treatments coming out that are more of a refined version of an already existing treatment, whether it's a different way of administration or a better side effect profile, better tolerated. There are also new classes of medications that are currently far along in being studied for MS, specifically the, a class of medication called the BTK inhibitors. So this is a promising new class of medications that has not yet been approved before for MS. And in addition to new medications coming out, I think as Anne mentioned, the field is leaning towards different treatment strategies for multiple sclerosis.

So, whereas in the past, one might start a newly diagnosed person on maybe a less effective therapy and then if the person has breakthrough disease, you might escalate to a more effective therapy. We're now leaning as a field towards treating patients sooner with the highly effective therapies, and we think that that makes a difference in their long term outcome.

And lastly, I'm hoping that in my career time, you know, we're gonna, maybe we'll even find a cure. There's a lot of research, and a lot of excitement around the aspect of finding remyelinating agents. So instead of using treatments to kind of stabilize a person and prevent any new neurologic disability, what the goal for a cure is really to figure out how to reverse the damage to the nerves themselves that are caused by the inflammation.

And I think that that's really promising and, hopefully we'll see that in the years to come.

Host: Absolutely. That would be such a breakthrough in MS treatment. Well, you both have provided us with wonderful information that really helps our audience understand MS. We're going to move on to the final take home question. What take home points about MS would you like to leave with our audience? Anne, let's start with you.

Anne Ocello, NP (Guest): MS is unique for every person and how it looks and how the disease course goes. So it's important to treat each person individually and taking care of the whole person.

Host: Mm hmm. I love that holistic approach. What about you, Dr. Nichols?

Jamie Nichols, MD (Guest): I completely agree with Anne and, I would say to you know, a person who's had a diagnosis of MS but maybe has not seen specialist for a number of years or has not started a disease modifying therapy or for someone who is newly diagnosed, the future is bright. MS is not the same disease it was even 10 years ago. There are such better treatments now, such a better understanding of the disease and there is not only a focus on better treatments and finding a cure, but also taking care of the whole person.

As you mentioned, holistic care is a huge priority for us. So the disease modifying therapy is one arm of treatment. And then we also focus on symptomatic management, managing someone's existing symptoms and optimizing their physical health, their emotional, mental wellbeing to really just make someone as healthy as they can be.

Host: Wonderful. Well, thank you so much for joining me today and taking time out of your day to really explain MS to our audience.

Anne Ocello, NP (Guest): Thank you.

Jamie Nichols, MD (Guest): Thank you so much.

Host: Once again, that was Nurse Practitioner Anne Ocello and Neurologist Jamie Nichols, who is the Director of the Maimonides MS Care Center. Thank you so much for joining me today on Maimo MedTalk. I'm your host, Dr. Rania Habib, wishing you well. Call 718-283-7470 to make an appointment. For general information, visit maimo.org. That's M-A-I-M-O.O-R-G. If you found this Maimo Med Talk podcast helpful, please share it on your social media channels.

To listen to additional episodes of Maimo Med Talk, please visit Maimo.org.