Transcription:
Treatment Decisions for Multiple Sclerosis (MS)

Melanie Cole (Host): Welcome to Back To Health, your source for the latest in health, wellness, and medical care. Keeping you informed, so you can make informed healthcare choices for yourself and your whole family. Back To Health features conversations about trending health topics and medical breakthroughs from our team of world-renowned physicians at Weill Cornell Medicine.

I'm Melanie Cole. And joining me is Dr. Ulrike Kaunzner, she's an Assistant Professor in Neurology at Weill Cornell Medicine and an assistant attending neurologist at New York Presbyterian Hospital Weill Cornell Medical Center, and she's here to tell us about treatment decisions for multiple sclerosis.

Dr. Kaunzner, thank you so much for being with us today. As we get into this topic, and there are so many really exciting treatments in your field right now for MS, tell us a little bit about what's going on today, the different types, the average age of onset. Kind of give us just a little brief overview of MS.

Dr Ulrike Kaunzner: Hello. Thank you very much for having me today. So, a very important question and good question about what is going on today, since there have been many changes over the last 10 years where we actually got many more medications approved and on the markets and have a much wider range of treatment options that we can choose from.

And first of all, to briefly talk about MS, MS is an inflammatory disease of the central nervous system, meaning of the brain and the spinal cord. And it classically presents with demyelination, meaning loss of the myelin in relation around the nerve sheath. And it also has a neurodegenerative aspect and it actually contributes or is the neurological disease with the highest level of disability in young people.

And so there are different forms of MS. There is this very classic relapsing-remitting MS where someone has a relapse, a flare, an attack, and then ideally comes back to baseline or to a new baseline. And then there's this progressive MS. And relapsing-remitting MS is mostly starting occurring in patients in their 20s and 30s; progressive MS, more in patients in their late 40s, 50s. And interestingly also, with the relapsing remitting type, this is actually more found in women. And we always said classically that about two times more women are affected from relapsing-remitting MS. However, probably the newer studies show that it's actually at a ratio of three to one women to men.

And in addition, I briefly want to mention this because this is also something that we discuss more and more, is that there's a new entity that we actually do not treat. However, it's very interesting because we know about this for about 13 years. This is called RIS, radiologically isolated syndrome, meaning lesions that look like classic MS lesions that are found on an MRI that was done for something completely unrelated, maybe some headaches or maybe for a car accident. And this is also a very interesting new finding that we try to observe and monitor very closely.

In terms of treatments, we have three different types of treatment groups broadly speaking. We have injections. These are the medications that we have actually for the longest, since the mid-1990s. And then we have pills. We have most of the pills actually for the last about 12 years. And then, we have different types of infusions. The first infusion we got in 2004 and the other infusions we got approved over the last few years.

Classically speaking, the injectables are more immunomodulatory and they are milder in terms of side effects and they also have a lower relapse rate reduction risk, except for one which is rather new, that is Kesimpta, that is an immunosuppressant and has a completely different mechanism. And then, the oral medications have different side effects. Some of them actually are also more immunomodulatory and don't have such a severe side effect profile, while others are actually quite strong. And then the infusions have probably the strongest relapse rate reduction rates. However, we do have now very strong pills and one injection as well that are very potent.

Melanie Cole (Host): What a comprehensive answer. And you are such a great educator. That was really great the way you described how they all work. You mentioned Kesimpta, which has a different way of working, and that's been recently approved. Speak about that.

Dr Ulrike Kaunzner: So Kesimpta has been approved in 2020, and it is a very interesting mechanism because it's called ofatumumab and it reduces B-cells. And we have used a B-cell medication kind of off-label for a long time. And then, it was a quite novel and beautiful finding and discovery that B-cells, once we keep B-cells in check or reduce them, circulating B-cells circulate them to a significant low level. And effectively, actually the circulating number of B-cell type will be zero, that this is really very effective in reducing relapses. And we have always used infusions, one off-label for a long time and then a new one kind of discovered and developed out of other infusions that we used before, the new one is called Ocrevus, ocrelizumab, and is given every six months over several hours.

The new medication, Kesimpta, can be given on a monthly basis and can be given by the patient herself or himself, which actually is, for some people, a little bit of a scary thought and scary experience. But others actually really prefer this independency from an infusion center or not have to come to an office for a strong medication. And it has been shown that it actually reduces relapse rate by about 59%. We probably will see more real life data. And it probably has a stronger level than this, I boldly say. And it reduces B-cells on a monthly basis and keeps them really nicely low. And, so far, I have a couple very young patients who are very pleased with it who are actually somewhat digital nomads or live abroad, or really enjoy that they can do a video visit or just check in in-person once a year, once every two years, because they can be so flexible with it and we can do blood work to check somewhere else.

Melanie Cole (Host): Well, it certainly is a comprehensive approach. And you described that very well. And why is shared decision-making such an important part of MS treatment, so the patients and their doctor work together? Because as you've said in your armamentarium now, there's so many treatment options.

Dr Ulrike Kaunzner: Good question. And this is really something that is widening or growing every year because we have new medications. We also have new knowledge on all these new medications. And I think it is very beautiful that we have these different options now. And I personally like to take my patients through these different options and actually narrow certain medications down to the suggestions I have. However, also listening very carefully to what the patient wants and needs and also what the circumstances in life are, and also probably what the risk level is.

So it depends on multiple factors. It depends on the type of MS. It depends on the severity of symptoms and relapses. It also depends on objective findings. If someone has minimal symptoms and based on the McDonald criteria to just have the MS diagnosis, I might not come with the strongest medication right away. If someone has really significant relapses, maybe comes now the second, did not want to be treated the first time or even the second, third and fourth time, has a significant lesion load, then I really would like to go for strong medications right away. So these are very important aspects.

Then, it's important, is it a young woman who would like to get pregnant within maybe two years, maybe within five years? Is it maybe a patient in their 50s with comorbidities. So these are important aspects first of all, then I check for other infectious diseases. I check for one important virus that actually about 60 to 70% of us carry, it's called JC virus to see if there is qualification for certain medications, or if actually patients could not receive a certain medication.

And then, I discuss very carefully the side effects of the individual medications. Some patients do want something with a very, very low risk profile. Others really want to go full force and for a very strong medication with a high relapse rate reduction. So we do this in a careful discussion. I always like to write them all out and kind of show the patient what I think would make most sense in terms of the objective findings of the disease, et cetera, but then also carefully take into consideration where does the patient stand, what have I learned in terms of anxiety concerns, where they stand in terms of family planning, their job, maybe traveling a lot, et cetera.

Melanie Cole (Host): Well, there certainly is a lot to think about and what about things like mental health, because this is really a devastating diagnosis for some people. And with all of these treatment options, I know that this still can be pretty depressing. Tell us a little bit about self-care, any physical limitations, and I'd like you to reiterate how the Judith Jaffe Multiple Sclerosis Center at New York Presbyterian Hospital Weill Cornell Medical Center is helping with these kinds of comorbid situations.

Dr Ulrike Kaunzner: Aside from us as MS physicians treating relapses or keeping these attacks or relapses in check as best as we can do this, it's actually a very, very important aspect that we address all the time and with every patient, there are all these sites, symptoms and all related aspects that are occurring with MS, such as headaches or, of course, mood changes, depression, patients can have insomnia. They can have bladder issues, bowel issues. And bowel issues are at times very difficult to treat. Patients can have spasticity of muscles, stiffness and pain. They can have vision changes, problems with ambulation. There can be tingling and nerve pain. And all of these aspects can be addressed with either sending to our rehabilitation center or PT, really reemphasizing that exercise and being active and mobile is very, very important, staying mobile. We try to address insomnia. We sometimes try to discuss first relaxation methods and things such as, let's say, chamomile tea or melatonin. We need more data for melatonin, but we try to start with this first and then maybe discuss some medication or sending to our sleep center. Bladder issues are addressed. And we very much work interdisciplinary here in our Judith Jaffe MS center, with all these different colleagues and centers. We send regularly to urology. We send to the GI team. For spasticity and muscle stiffness, we can, again, recommend relaxation and stretching. However, we also recommend our rehab center. Vision changes, we work very closely with our neuro-ophthalmology team where OCT, optic coherence tomography, is obtained. And then, actually, if needed, an annual followup or more frequently. And of course, tingling nerve pain, we also try to address.

And then aside from these symptoms, so first keeping the relapses in check, then treating this by symptoms of MS, then we also very much reiterate in our center and try to really focus on a more holistic approach, which is very beautiful. So we really try to emphasize how important good sleep is or how important relaxation and stress reduction is. This is a very important aspect, actually. And I always try to mention this to my patients as well, because we actually know, I worked in a stress lab before, that neuroplasticity, meaning branching of nerve cells actually does not work well in a stress environment. And if the brain is challenged already, and we add a lot of stress on top of this, this is of course not a good combination. Then, we reiterate exercise, yoga, stretching. And of course, aside from the more quiet exercises, ideally also some cardio exercise. And also very important is cognitive engagement. Working being in a job, doing something that someone enjoys that's not too stressful is actually very good for the brain. Also, doing other things that are challenging to the brain. If someone enjoys word games or playing chess or playing an instrument, these are all very, very good things for the brain and, again, for neuroplasticity. And social interaction is also very important for overall brain health.

And then, we also try to emphasize always how important food is. I mean, we have a couple contributing factors where we know that they might contribute to the onset of MS. However, we don't have one and only trigger and things such as these surrounding aspects and particularly food can be quite helpful. The gut is a huge nervous system and it's a huge immune system. And keeping the gut health is also very important and we like to discuss all this in our center.

Melanie Cole (Host): I love that. What a holistic approach that you take. And it's so important for patients living with MS, because with all of the things going on and the fear and all of it, you're really taking this whole body approach to help them with all the different parts. Can you wrap it up for us, doctor, and give us your best advice for people listening that want to know about all the exciting advancements going on in the world of treatment for MS and what you're doing at Weill Cornell Medicine?

Dr Ulrike Kaunzner: So here in our center, we have a very kind-- I did my fellowship here and I'm very happy that I'm staying on. We have a very kind team and it's very nice to hear this from the patients as well. We have our own infusion center. We have a nurse practitioner who is actually taking care of our patients and we have five MS specialists working very closely together. And it is a center that also has a huge interest in this holistic approaches. We do a lot of basic research. There is a lot of clinic research. We actually work on different MRI sequences, as well as novel imaging techniques, such as PET. And of course, we also engage in clinical studies. So there is a lot going on here. And we also, as I mentioned, work very comprehensively with these other specialists and centers.

And in terms of what is new, I mean, there are many new medications and trials out there that have probably different mechanisms, also address different immune cells, also actually in the brain, because many medications work most in the periphery actually do not go into the brain. And in our center, we really try to keep the whole human being in mind, which is so important. And I think this is a very big emphasis here. And it is very important to really look at the entire body to really try to keep body and mind happy and healthy as much as possible. And this is very important to really help with this inflammation of the body and to really try to assist with all the above-mentioned aspects.

Melanie Cole (Host): One-hundred percent. What an informative podcast this was, doctor. Thank you so much for joining us today with your lovely passion, and we can hear that in your voice and your incredible expertise, in this field. Thank you again. And Weill Cornell Medicine continues to see our patients in person, as well as through video visits. And you can be confident of the safety of your appointments at Weill Cornell Medicine.

That concludes today's episode of Back To Health. We'd like to invite our audience to download, subscribe, rate, and review Back To Health on Apple Podcast, Spotify and Google Podcast. And for more health tips, go to weillcornell.org and search podcasts. And parents, don't forget to check out our Kids Health Cast. I'm Melanie Cole,

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