Multiple Sclerosis Medications: Making the Most of a Multitude of Options (Podcast)

The multiple sclerosis (MS) treatment landscape has changed enormously since the first disease-modifying therapy was approved for the condition by the FDA in 1993. Today there are numerous injectable, oral and infused medication options, mostly for relapsing-remitting MS and progressive MS with concomitant relapses.

“Although we’ve made significant advances and strides in our ability to treat MS, there’s still a lot to be desired,” says Alise Carlson, MD, a neurologist in Cleveland Clinic’s Mellen Center for Multiple Sclerosis Treatment and Research. “We need to work on developing therapies that target the worsening of the underlying neuropathological issues, and then reverse damage and restore function. Those are the things we have to look forward to in the years to come.”

In the latest episode of Cleveland Clinic’s Neuro Pathways podcast, Dr. Carlson discusses the treatment landscape for MS, including:

• A detailed chronology of MS therapeutics, from interferon formulations to monoclonal antibody treatment
• Counseling patients on the right treatment approach
• Medication strategies for pregnant patients and those who plan on starting a family
• Common side effects and complications, and the importance of monitoring them
• Emerging therapies, including stem cell transplantation

Click the podcast player above to listen to the 28-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.

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Excerpt from the podcast

Podcast host Glen Stevens, DO, PhD: Let’s suppose I am diagnosed with relapsing-remitting MS and come to see you. You show me the flow chart with all the drugs on there. How do you counsel me as to which drug I should take? It seems dizzying.

Dr. Carlson: That’s right, and if you present it in that manner or present every single medication to every patient, it’s absolutely overwhelming. I typically introduce the concept of disease-modifying therapy as starting a medication that aims to correct this overactive or aberrant immune system that is causing damage and wreaking havoc in the central nervous system. Then I explain our treatment approach in terms of the currently prevailing treatment strategies, of which there are two.

So, the classic treatment approach is what we call an escalation approach, where we choose a medication that may have lower or moderate efficacy but a more favorable safety profile, and then we escalate to a highly effective therapy only if there is breakthrough disease activity. In other words, we lean on the medications that we’ve had more experience with and then escalate to these more aggressive therapies if needed. And the more aggressive therapies are the newer ones, as therapies have generally become more efficacious over time.

More recently, there has been a lot of interest in what we call an early highly effective treatment approach. That’s where we start with a highly effective therapy at the time of diagnosis to control the disease activity early, when it’s most active and we think we can make the most impact on the long-term disease outcomes. The concept has been that these more highly effective therapies carry more risk, in terms of infections and perhaps severe side effects. There’s considerable research going on to further quantify and qualify exactly how significant those risks are, but we also have to keep in mind that the escalation approach carries risks as well. They include a higher likelihood of breakthrough disease activity. Plus, some of the lower- or moderate-efficacy therapies can have more tolerability issues in the long run, which can result in nonadherence.