Posted by: Thixia | April 1, 2008

Video – Treatment of Early MS – Options

  Treatment of Early MS: What Are Your Options?


In its early stages, multiple sclerosis comes and goes in a series of attacks that can be separated by months or years. An actual diagnosis can’t be made until after at least two attacks have occurred in different parts of the nervous system, meaning that treatment wouldn’t start until long after the disease first appeared, but there’s a new school of thought that calls for a different approach. Tune in as Dr. Steven Galetta talks about the treatment for early multiple sclerosis.


DAVID MARKS, MD: Hi and welcome to our webcast. I’m Dr. David Marks.

In its early stages, multiple sclerosis comes and goes in a series of attacks that can be separated by months or even years. But doctors can’t diagnose MS until a patient has at least two attacks. Now that used to mean that treatment couldn’t start until long after symptoms first appeared. But now some experts are calling for a different approach.

Joining me to talk about this is one expert: Dr. Steven Galetta, a neurologist at the University of Pennsylvania. Welcome.

Now what is MS to begin with?

STEVEN GALETTA, MD: MS is an immune attack against the central nervous system; that is, the brain and spinal cord. And the immune cells attack the coverings of the cables of your brain called “myelin.”

DAVID MARKS, MD: Now we talk about MS coming and going. Describe what a patient goes through and how it’s diagnosed.

STEVEN GALETTA, MD: There are attacks, what we call “exacerbations” that may evolve typically over several days and then, often, in the earliest stages of MS, remit. Usually, that is, the patient improves after their neurological problem. It may take several weeks to maybe a few months to improve. So these are attacks that are somewhat unpredictable in the earliest stages of the disease that may occur separated by many months or even years at a time.

DAVID MARKS, MD: Do they occur in the same parts of the body each time?

STEVEN GALETTA, MD: No, I think it’s a random type of event in many people. For instance, it could occur the first time in the optic nerve. The next time, it might be an event that occurs in the spinal cord.

DAVID MARKS, MD: Is this the only kind of MS that there is?

STEVEN GALETTA, MD: That’s the early stage of MS and it accounts for 85 percent of patients in the earliest stages of multiple sclerosis. That is, they have an event that occurs and then it often remits. There are other stages of MS — secondary progressive MS — really is characterized by episodes that have occurred and now disability starts to accumulate over time. So the patients had a number of attacks and now they may have trouble walking, for instance. That’s secondary progressive MS, and there are more rare forms of MS in which the course is a steady downhill course and we refer to that form of MS as a “primary progressive MS.”

DAVID MARKS, MD: If a person has the first event, can they be diagnosed with MS?

STEVEN GALETTA, MD: By clinical definition, we have traditionally required that a patient have a clinical attack, say optic neuritis, and then separated by a month they have a second attack. So MS — to fulfill the clinical standard definition of MS required two episodes of clinical attacks separated by a month.

We’ve come to recognize, however, that there is a group of patients who have a single attack, their first attack that are at high risk to develop MS and we have determined that by their MRI scans. Those patients who have had a single attack with an abnormal MRI scan are at increased risk of multiple sclerosis over both the short- and long-term.

DAVID MARKS, MD: Traditionally, when have doctors started treating patients?

STEVEN GALETTA, MD: As we’ve recognized that MS may, in the earlier stages, be quite silent, only evident on an MRI scan, we’ve pushed this treatment envelope to earlier and earlier. And in fact, many patients who have had a single attack who have a positive MRI scan are candidates for early therapy.

DAVID MARKS, MD: What’s the benefit of starting therapy so early, and are there any downsides to that?

STEVEN GALETTA, MD: I think the benefits of catching the disease early is to lessen the risk of disability. We don’t have a lot of long-term studies with any of the current available medications for multiple sclerosis, but we feel that there is evidence to suggest that those patients that start early on therapy are doing better than those that have waited or those that were in trials that were on placebo.

David Marks, MD: What are the treatments that doctors should think about with patients who maybe are early on in the course of the disease?

STEVEN GALETTA, MD: Early on in the course of the disease for relapsing remitting MS, we now have four drugs that are most often used. And they are Avonex, Betaseron, Copaxone and Rebif. For the earliest stages, the monosymptomatic patients that we’ve just been talking about, Avonex has been the drug that’s been studied in this subgroup of patients. And this study is known as the CHAMP study, which established the efficacy of this medication.

DAVID MARKS, MD: Is it hard to convince a patient who has maybe only had one event to undergo treatment that has potential side effects?

STEVEN GALETTA, MD: Yes, I think it is. It’s a lot for a patient to absorb. The first time they come into your office, you have to go through a lot of different things. You have to explain to them what this event was, what’s the prognosis and then there’s a very complicated, in some sense, regimen that we have to go through. We have to get an MRI scan to see or establish the risk of future events, because if they develop a new lesion on an MRI scan, that really tells us that they have multiple sclerosis at that time. Even though they didn’t clinically have an event, the MRIs told us that the disease is active and that this is multiple, that we do have a second event separated in time by at least one month. So I think that neurologists are now using the MRI scan a lot more frequently to help them diagnose multiple sclerosis.

DAVID MARKS, MD: Now for the money question: Do you think that every patient with a single event should be treated with one of these drugs?

STEVEN GALETTA, MD: I think it should be carefully considered. And I think it should be carefully considered in those patients that have positive MRI scans, MRI scans that show lesions in other areas.

DAVID MARKS, MD: Dr. Galetta, thanks for being with us. And thank you for joining our webcast; I’m Dr. David Marks, goodbye.


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