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January 24 Highlight and Commentary

Therapeutic decision making in MS: Impact of a slower disability progression

Tremlett et al. examined the natural history of MS in British Columbia, Canada. They found that MS progression is slower than in earlier studies. They also challenge two fundamental concepts in MS, demonstrating that neither male subjects nor those older at onset had a worse disease outcome.

see page 172

Therapeutic decision making in MS: Impact of a slower disability progression

Commentary by Sean J. Pittock, MD

Given the widespread tendency to initiate disease modifying agents (DMA) for MS at the time of the earliest symptom, the "watchful waiting" approach of clinicians skeptical of their long-term value is becoming more difficult to pursue. Nevertheless, the decision to start potentially lifelong treatment with an injectable medication must be based on many factors, including available data from clinical trials demonstrating modest short term benefits, an appreciation of the patient’s attitude to long term treatments despite the uncertainty of long term outcomes, and an estimate of the patient’s individual risk of disability based on knowledge of the natural history of the disease.

Some MS experts have argued that benign MS does not exist, no matter how it is defined. However, new studies of the course of MS have shown that many patients develop only mild disability after long follow-up. Tremlett et al’s study of a large population-based MS cohort from British Columbia, Canada, reports a favorable clinical course for many patients, similar to that reported from Olmstead County, MN, and Lyon, France.^1,2

The changing attitudes to treatment of this disease are reflected somewhat in the recently modified, and now less directive, recommendation from The National MS Society. Rather than stating that the Society "recommends initiation of a DMA as soon as possible following definite diagnosis of MS with a relapsing course," it advises that "treatment should be considered as soon as possible following a definite diagnosis of MS with active disease." The challenge for the future is to identify at an early point in the course of MS those who will do well without treatment and those who will not.

see page 172

References

1. Pittock SJ, Mayr WT, McClelland RL, et al. Disability profile of MS did not change over 10 years in a population-based prevalence cohort. Neurology 2004;62:601–606.[Abstract/Free Full Text]
2. Confavreux C, Vukusic S, Moreau T, Adeleine P. Relapses and progression of disability in multiple sclerosis. N Engl J Med 2000;343:1430–1438.[Abstract/Free Full Text]

This Article Full Text (PDF) Correspondence: Submit a response Alert me when this article is cited Alert me when Correspondence are posted Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via Google Scholar Google Scholar Search for Related Content PubMed PubMed Citation Related Collections Related Article