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The Madlyn Borelli Multiple Sclerosis Center at Montefiore Nyack Hospital

Deborah Howell (Host): Multiple sclerosis effects millions of Americans. Finding a skilled provider is key to living with the condition. Welcome to our health talk podcast. I’m Deborah Howell and we’re here today with Dr. Jai Perumal, director of the Madlyn Borelli Multiple Sclerosis Center Montefiore Nyack Hospital. Serving Rockland County and the lower Hudson valley. Patients travel as far as 100 miles to seek MS treatment from Dr. Perumal and her team of committed MS experts. Today we’ll be talking about treatment options for patients with multiple sclerosis. Thank you so much for joining us Dr. Perumal.

Jai Perumal, MD (Guest): Deborah, it’s a pleasure to join you on this podcast.

Host: Hey listen, you must have something very special going on at the Madlyn Borelli MS Center for patients to travel so far to see you and your team. My first question to you is simply what is multiple sclerosis?

Dr. Perumal: So multiple sclerosis is an autoimmune disease that effects the central nervous system. So that means somehow your immune system gets triggered to produce these cells that are circulating in the blood and then they gain access into the brain and they're causing injury. So, the central nervous system includes your optic nerve, the brain, and the spinal cord as well. So, lesions can happen in any of these areas.

Host: And what are some of the most common symptoms of MS?

Dr. Perumal: That would depend on where the patient developed the lesion. Since it can affect all of those areas, let’s say somebody developed a lesion in the optic nerve, that would manifest as having problems seeing out of one eye. If it develops in certain parts of the brain, it could be anything. It could be anywhere from having numbness or weakness in the arms or legs or one side of the body. Or it could be problems with speech or balance. Or it could be problems with bladder. So, since the brain controls pretty much all our functions, depending on where the lesions are, patients could present with one or more or any number of symptoms.

Host: And is it a progressive disease?

Dr. Perumal: You know, there is a lot of debate as to whether MS is just inflammatory or whether it’s a degenerative disease. Over time there can be disease progression. The typical form of MS is what we call relapsing remitting where patients have a symptom or a relapse, and then over the next few days they recover, and they can go back to being completely normal. Then they could have another relapse and recover from that. So that up and down pattern is what we call relapsing remitting. About 85-90% of patients who are diagnosed with MS have the relapsing remitting form.

Over time it can change from having that up and down pattern to where problems kind of don’t come all of a sudden but can slowly accumulate or change over time. That phase of the disease is what we call secondary progressive disease. So, patients with relapsing remitting can transition to what we call secondary progressive disease. A much less common form of MS is what we call primary progressive MS. Here patients don’t start out with having that up and down relapsing form, but rather start noticing problems with walking or gait or endurance. It seems to slowly get worse. That form of MS is called primary progressive disease.

Host: Is stress a factor in relapse?

Dr. Perumal: So, stress definitely can make MS symptoms worse. Whether it goes on to be a full-blown relapse may or may not happen. But whenever our patients go through periods of stress, there can be a worsening of MS symptoms even though they don’t have a classic relapse. One thing that was interesting in this regard is a few years ago out of Yale they did a study looking at MRIs in patients who were… They had two groups. One was a group of patients who had a stress management intervention and the other group did not have the intervention. They were the control group. Based on their study of MRIs, it looked like patients who did not have the intervention actually had more legions called active legions. So that was a small study, it was one study, but again that demonstrated that stress could have an impact on inflammation. As a consequence, have patients develop a relapse or have new legions because of stress. One thing we do see often is when patients go through periods of stress, for whatever reason whether it’s personal or professional, they do seem to have a worsening of their existing MS symptoms.

Host: Yeah. That would just make sense. Now anyone can get MS, but are certain ethnic groups more prone to contracting the disease than others?

Dr. Perumal: So, MS, like a lot of diseases, it’s a combination of having certain genetic predisposition. If you get a certain set of genes, it puts one at a higher risk of getting MS. In addition to that, there have to be certain environmental triggers that come into play as well. It’s almost like a perfect storm, you know? In the right genetic setup, if a patient encounters certain set of environmental factors at certain points in their life, it can trigger off MS.

With regard to ethnicity, MS is more common in North America and western Europe. It is more common among Caucasians. One thing that is interesting is when you look at some of the newer studies looking at the incidents of MS, it appears that even among African Americans the incidents is increasing, or it is close to the Caucasian incidents. Traditionally, it is much more common among the Caucasian population compared to African Americans. The couple of recent studies seem to point that the incidents in African Americans seems to be quite high too. So that may be a change we are seeing over time.

Host: Okay. And do the treatments vary for patients of different ethnicities?

Dr. Perumal: So overall, even though MS presentations can be similar, the underlying immune mechanisms can be different in different patients even within the same ethnic group. But generally, African Americans tend to have a more aggressive disease with more problems with gait or cognition. Some of the milder treatments may not be that effective in that group compared to Caucasians. So, we have to move towards more personalized medicine since we have several options to treat MS. Trying to find the right fit for the right patient and including ethnicity as one of the factors that should help determine the best fit is quite helpful as well.

Host: Well personalized medicine is always a good idea. Let’s talk about some of the treatment options for patients with MS that are currently offered at the Madlyn Borelli MS Center. Can you speak to that?

Dr. Perumal: Yes. So, there are, you know… We live at a time when there are several options. A couple of decades ago, the treatment options for MS was quite limited. So, we are very fortunate to have a whole spectrum of treatments that we can offer patients. So, like as mentioned before Deborah, we have to find the right fit for the patient. So, we have some drugs that may not be that effective. Now, keep in mind, the treatment of MS is controlling the immune system. So, depending on how aggressive the disease is, we may need to control the immune system that aggressively too. So, when a patient presents with a milder form of the disease, we don’t necessarily have to put that patient on the most aggressive or immune suppressive treatment. But on the other hand, if we see a patient who presents with a lot of symptoms. We look at the MRI and that has a lot of lesions and we are concerned that this patient may be on the aggressive spectrum of the disease, we don’t want to waste time putting them on a drug that is kind of mild immune modulating treatment which may not be effective. Because the most important takeaway thing about MS treatment is that our treatments work very well in the beginning.

Host: Yes.

Dr. Perumal: It’s almost like we have a window of opportunity to treat the disease. So, we have to make sure that in the early part of the disease, we have to get the patient on optimal treatment so that they don’t have any more relapses, they don’t have any changes on MRI so that 20/30 years down the road, we can really make a difference in terms of their disability. Unfortunately, if too much has happened in the early part of the disease where patients continue to have relapses or continue to have changes on MRI, it is very hard to get the disease under control later. Once patients develop fixed deficit, unfortunately we don’t have any treatments yet that bring them back.

So, the most important thing providers have to keep in mind, and even patients so that they can advocate for themselves, is to get the disease controlled very well in the beginning. That doesn’t mean everybody has to be on the aggressive. Depending on their disease, depending on their preference. Again, going back to personalized medicine, we have to find the right fit for the patient early on.

Host: Absolutely. Dr. Perumal, I have a friend with MS who says she feels much better when she travels to France where GMOs are forbidden in all foods. What’s your reaction to that?

Dr. Perumal: So, there is a lot of debate about diet and MS, including supplements or foods that can be proinflammatory or anti-inflammatory. Right now, the data we have that seems to definitely have an impact on MS is vitamin D. So, it seems quite well established in adult population and pediatric population that a low vitamin D is at risk for MS or is at risk for inflammation or disease progression. So that is something we do recommend to patients to make sure they’re supplementing a vitamin D so that their vitamin D levels are not just normal, but a high normal level. With regard to other aspects of diet, I do have several patients who mention a particular kind of food or diet that makes their MS symptoms better. But there is not enough data to make a specific recommendation.

Host: As always, much more research needs to be performed.

Dr. Perumal: Absolutely.

Host: I'm sure it will be, and I know you even personally are right on top of that.

Dr. Perumal: Yes. You know we are fortunate in that we have learned a lot about MS and that has translated to much better treatments and much better outcomes for our patients, but it is still a field where a lot more needs to be learned. Now there is a lot of research looking to see if the gut microbiome is somehow a trigger for MS. That will provide a lot of data for us about diet. Habits like that that can influence the risk of getting MS or the MS getting worse. So yes, we have come a long way, but we still need to explore more so that we can treat patients more effectively and make sure that their level of disability is kept down.

Another major need we have in terms of MS treatment is regenerative therapies. You know now just treatments that control the immune system and prevent the disease from getting worse, but also bringing back function. Whether it is stem cell or remyelinating therapies. We have a lot of work to do in that aspect of the disease.

Host: Well, it is an exciting future for patients with MS with so many options around the bend.

Dr. Perumal: Absolutely, yes. It is a great field to be in, you know. To be able to actually offer patients treatment that could have positive impact for their life. So, MS and neurology in general has come a long way. I’m very, very optimistic that we’ll continue to get better.

Host: Well thank you so much Dr. Perumal for taking time out of your busy day to be on the podcast today. We really appreciate it.

Dr. Perumal: It’s my pleasure. Thank you so much.

Host: I'm Deborah Howell. Thank you so much for listening to this episode of our health talk podcast. Head on over to our website at montefiorenyack.org to get connected with one of our providers. If you found this podcast helpful, please share on your social channels and be sure to check back in soon for the next podcast. Have yourself a terrific day.