Diagnosing and Managing Multiple Sclerosis: A Personalized Approach
Multiple sclerosis (MS) affects nearly 1 million Americans.1 -3 Among young adults, MS is a leading cause of disability4 and reduces life expectancy by 7 to 14 years.5 Peak prevalence of MS occurs during the prime ages of employment for men and women; women are approximately 3 times more likely than men to acquire MS.1,6
Due to intrinsic and extrinsic factors, the management of MS is challenging, heterogeneous, and unpredictable. Among affected individuals and by subtypes, MS manifests with varying clinical presentations of relapses with partial to complete recovery and/or slow disease worsening. An understanding of MS pathogenesis, which can importantly inform therapeutic strategies, remains incomplete. For example, a distinct pathologic process was recently reported in a newly discovered subtype, myelocortical MS, in which hemispheric central nervous system (CNS) myelin is curiously spared.7 The fact that most people with MS are women of reproductive age poses distinct challenges for selecting pharmacologic therapy that may increase fetal risks. Other management challenges exist in the selection of an appropriate disease-modifying therapy (DMT) from an increasing number of options; in ensuring patient access to DMTs; in monitoring the overall safety and tolerability of prescribed DMTs; and in keeping up-to-date with evolving best practices. Notably, the McDonald criteria for diagnosis were revised in 2017,8 and in 2018 the American Academy of Neurology (AAN) published updated practice guidelines for DMT use in adults with MS.9-11
While MS is managed primarily by general neurologists and MS specialists, members of a multidisciplinary health care team play crucial roles in the coordinated care of people with MS.12 Over the course of the disease, a person with MS may interact with a variety of health care professionals to engage in shared decision making (SDM) about therapeutic interventions. By taking into account a patient’s goals, values, and preferences and by relying on the expertise of health care professionals, SDM becomes a collaborative process whereby treatment adherence is promoted and favorable outcomes can be realized.13,14
Multiple sclerosis (MS) is one of the leading causes of disability and many efforts have been implemented to help expediate diagnosis and initiate early, effective treatment. With rapidly changing guidelines and treatment indications, it can be difficult discerning when to start a disease-modifying therapy in the early spectrum of MS, such as clinically and radiologically isolated syndrome; how to discuss MS management in women of childbearing age; or how to use the new guidelines to confirm an MS diagnosis. In this supplement, these topics will be addressed along with recognizing treatment failure, knowing when to switch therapies, and how to incorporate patient preference in treatment-related decisions.
After completing this activity, the participant will demonstrate the ability to:
- Recognize and diagnose the spectrum of multiple sclerosis (MS), from clinically isolated syndrome (CIS) to the various forms of MS (ie, relapsing-remitting and progressive) using established, updated, clinical imaging and laboratory criteria
- Appropriately use available and emerging disease-modifying therapies (DMTs) for MS based on their efficacy, safety, and tolerability profiles, as well as their approved or anticipated indications for the various forms of MS
- Recognize and manage treatment failure, including switching DMTs
- Monitor disease and patient outcomes, including patient adherence, according to recommended protocols
- Use shared decision making when prescribing DMTs to improve treatment adherence and patient outcomes
- Appropriately manage MS in women of child-bearing age
Patricia K. Coyle, MD, FAAN, FANA
Professor and Vice Chair, Clinical Affairs
Department of Neurology
Director, MS Comprehensive Care Center
Stony Brook University Hospital
Stony Brook, NY
JOINT ACCREDITATION STATEMENT
In support of improving patient care, this activity has been planned and implemented by the Postgraduate Institute for Medicine and RMEI Medical Education, LLC. Postgraduate Institute for Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.
Physician Continuing Medical Education
The Postgraduate Institute for Medicine designates this enduring material for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Method of Participation and Request for Credit
There are no fees for participating and receiving CME credit for this activity. During the period, September 30, 2019 through September 29, 2020, participants must read the learning objectives and faculty disclosures and study the educational content.
PIM supports Green CME by offering your Request for Credit online. If you wish to receive acknowledgement for completing this activity, please complete the post-test and evaluation on www.cmeuniversity.com. In the “Find Post-test/Evaluation by Course” field at the top of the page, search by course ID 14335. Upon registering and successfully completing the post-test with a score of 70% or better and the activity evaluation, your certificate will be made available immediately. Processing credit requests online will reduce the amount of paper used by nearly 100,000 sheets per year. If you have questions regarding the receipt of your e-mailed certificate, please contact PIM via e-mail at firstname.lastname@example.org.
This activity is jointly provided by RMEI Medical Education, LLC and Postgraduate Institute for Medicine.
This activity is supported by an independent educational grant from Genentech.
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Print and Online Journal Supplement
DISCLOSURE OF CONFLICTS OF INTEREST
Postgraduate Institute for Medicine (PIM) requires instructors, planners, managers, and other individuals who are in a position to control the content of this activity to disclose any real or apparent conflict of interest (COI) they may have as related to the content of this activity. All identified COI are thoroughly vetted and resolved according to PIM policy. PIM is committed to providing its learners with high quality activities and related materials that promote improvements or quality in healthcare and not a specific proprietary business interest of a commercial interest.
The faculty reported the following financial relationships or relationships to products or devices they or their spouse/life partner have with commercial interests related to the content of this CME activity.
Patricia K. Coyle, MD, FAAN, FANA, has affiliations with Accordant, Actelion, Alexion, Bayer, Biogen, Celgene, Genentech/Roche, Novartis, Sanofi/Genzyme, Serono, TG Therapeutics (Consulting Fees); Actelion, Genentech/Roche, MedDay, NINDS, Novartis (Contracted Research).
Postgraduate Institute for Medicine
The PIM planners and managers have nothing to disclose.
RMEI Medical Education, LLC
The RMEI planners and managers have nothing to disclose.
DISCLOSURE OF UNLABELED USE
This educational activity may contain references to published and/or investigational uses of agents that are not indicated by the FDA. The planners of this activity do not recommend the use of any agent outside of the labeled indications. The opinions expressed in the educational activity are those of the faculty and do not necessarily represent the views of the planners. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.
Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this activity should not be used by clinicians without evaluation of their patient’s conditions and possible contraindications and/or dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities.
The author would like to thank Barbara J. Martin, MD and Lobna Eldasher, PharmD for their assistance in writing and editing this manuscript. The individuals mentioned report no potential conflicts of interest and have given their written permission to be named.
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