Andrew N. Wilner, MD; Fred D. Lublin, MD; Robert J. Fox, MD


October 10, 2013

The Role of Relapses

Dr. Lublin: The other theme that came up was that earlier studies suggested that the relapses didn't matter once the patient hit a progressive phase, that it was the progression that was driving the disability. In progressive disease it is the slow progression that drives most of the disability, but it turns out that you can't ignore the relapses. There was a study from the Mayo Clinic[3] in which they interrogated their extensive database and looked at individuals with primary progressive MS and secondary progressive MS who had relapses during the course of their progression. The only difference between them was that the patient with primary progressive MS, who then has a relapse, then has progressive relapsing MS. In both cases the relapses matter. Patients did worse if they were having relapses in addition to progressive disease, and this highlights an inflammatory component to relapsing MS. The presenters raised the possibility that this could have therapeutic implications for an area of MS where we really don't have very good therapies. The other issue that came up was the role of relapses and how we can modify them. In all of our relapsing clinical trials, the agents that have succeeded reduced the number of relapses, but how about the severity of relapses?

Dr. Fox: A study that you were involved in, Fred, looked at the severity of relapses in patients in the phase 3 clinical trials for teriflunomide and natalizumab,[4,5] and in those 2 trials the severity of the relapses was less and the patients seemed to recover better when they were on active treatment than when they were on placebo. So we are now moving beyond just counting the number of relapses to also looking at the amount of injury that is incurred through the relapse. It is encouraging that our therapies not only reduce the numbers but also make patients better at the end and make the relapses less severe.

Environmental Triggers

Dr. Lublin: With respect to the role of environmental agents in MS, there was a discussion of how the incidence of MS has increased and the gender frequency has changed, so MS is becoming more frequent in women than in men. Because this has occurred relatively recently in time, it suggests that it can't be a genetic feature but rather an environmental feature.

Dr. Fox: Vitamin D appears to have an impact on disease.[6] Even in patients who are on therapy, low vitamin D is associated with a worse disease course and provides some ideas of things that we might be able to combine with our standard therapy, such as vitamin D supplementation. We also saw that not only does smoking predispose to getting MS, which we have known for a bit of time, but also it predisposes to MS being worse once it develops. It teaches us an important lesson that we should remember to encourage patients to stop smoking, and for those who are still smoking, that should be part of our care of their MS.[7]

Dr. Wilner: I would like to thank both of you for your comments and insights. This is Dr. Andrew Wilner, reporting from the ECTRIMS meeting in Copenhagen, Denmark.


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