In the past decade, more than 15 disease-modifying therapies have been approved to treat multiple sclerosis (MS). This proliferation of treatment options has led to a growing population of older adults living with MS, prompting providers to increasingly consider how age and disease duration impact MS progression and treatment.

“The revolution of medications has been fantastic,” says Le Hua, MD, Director of the Multiple Sclerosis Program and the Eric and Sheila Samson Chair for MS Research at Cleveland Clinic Lou Ruvo Center for Brain Health, Las Vegas. “People are getting older, they are surviving with less disability, they are doing better. What we don’t want to do is inadvertently keep someone on a medication when they no longer really need it.”

In the latest episode of Cleveland Clinic’s Neuro Pathways podcast, Dr. Hua discusses management of older adults with MS and why paradigms may need to shift. She delves into:

• How MS progresses in older adults compared with younger patients
• Consideration of immunosenescence ― a common part of aging ― in therapeutic decision-making
• Results of studies investigating discontinuation of medication in older adults with MS
• The importance of considering comorbidities, separate from MS symptoms, that can lead to patient decline
• The potential for biomarkers to predict treatment response and disease status

Click the podcast player above to listen to the 30-minute episode now, or read on for a short edited excerpt. Check out more Neuro Pathways episodes at clevelandclinic.org/neuropodcast or wherever you get your podcasts. This activity has been approved for AMA PRA Category 1 Credit™ and ANCC contact hours. After listening to the podcast, you can claim your credit here.

Excerpt from the podcast

Podcast host Glen Stevens, DO, PhD: Where is research heading for the patient population as they age? What are we looking at other than trying to determine how long patients should stay on medication?

Dr. Hua: What I mentioned earlier is that we want to discontinue therapy that might be immunomodulatory because if that’s not the underlying process that’s causing patients to worsen, we don’t want to be treating with a therapy targeting the wrong process.

We know that our patients with MS undergo neurodegeneration and they have loss of axonal integrity. They have chronic smoldering inflammation within their brain ― something we term inflamm-aging.We know that there’s decreased energy use, decreased ability to utilize mitochondria, decreased ability to remyelinate. The macrophages don’t clear debris as well. There are many other processes happening in the brain.

What we really want to study in our older patients is what the underlying biological process is that’s causing worsening that might be a better treatment target. Rather than treating the immune system, we want to develop therapies that help with neuroprotection, and we want to develop therapies that might help with regeneration or restoration of function.

I think that’s going to be key in the research as we study not only young patients and how to stop relapses from occurring, but how to really stop progression. And how we can help patients who are undergoing different aspects of their disease, different processes, and actually target with the correct therapy.