Andrew N. Wilner, MD; Heinz Wiendl, MD


October 30, 2013

Editor's Note:
While onsite at the European Committee for Treatment and Research in Multiple Sclerosis (ECTRIMS) 2013 annual meeting in Copenhagen, Denmark, Medscape correspondent Andrew N. Wilner, MD, spoke with Heinz Wiendl, MD, Professor of Neurology and Chair of the Department of Neurology in Münster, Germany, about establishing treatment algorithms in multiple sclerosis (MS).

Dr. Wilner: Dr. Wiendl, we just listened to a presentation[1] about the treatment of MS and an attempt to establish some sort of treatment algorithm for choosing which drugs are best for which patients. One of the questions that comes up is: When should one change therapy? In other words, you have decided on a particular treatment course, and the patient now has a symptom or an MRI change. What is enough to say that this isn't working? How do you approach that question?

Dr. Wiendl: This is a straightforward question, but it does not have a very simple answer because it depends on the patient's history of relapses. Let's say the patient came from 5 relapses. You reduce the relapse rate to 1 per year, which is a tremendous relapse reduction. One relapse in that patient wouldn't bother me. If you have a patient who was stable for 2 years -- stable with no relapse -- and then has 2 relapses, that is too much. So it depends on the comparison of history vs the actual situation. That is one aspect.

The other aspect is your treatment goals. The treatment goal, ambitiously spoken, is no more relapses -- at least no more severe functionally disabling relapses, no more significant activity on MRI, and definitely no more disability progression or accumulation of symptoms related to MS. Those are the 4 factors that I consider in my patient when making decisions. If 1 out of these 4 shows a movement, I begin to become vigilant. If it's more than 1 and if it repeats, then I usually switch therapy.

Dr. Wilner: One of the 4 was a significant MRI change?

Dr. Wiendl: Yes. That is a difficult one because if you compare MRIs from different devices or different investigators, you might see a subtle lesion that wouldn't count. But if the same evaluator sees, perhaps, 2 lesions, then that would be significant. It's not just the lesion, per se, it's the floridity, the dynamics, and the conversion of lesions into black holes.

So it's more than just a number. One lesion is not sufficient, but 2 might be sufficient, and 10 certainly is. It depends a bit on the standardization. One lesion makes me alert. With more than that, especially a combination of changes on MRI, I am more alert and willing to consider a therapy change.

Dr. Wilner: Before we had all of these oral options, we used to switch between the interferons. Is that still an option? If you have tried an interferon, do you just go to a different category of drug, or would you be willing to continue to switch within the interferon group?

Dr. Wiendl: I personally don't see this anymore as a very favorable approach. So a simple answer is that we don't do that anymore because we think it's the mode of action that is relevant, so we would switch to a different category of drug with a different mode of action.


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