Dec 7th, 2002
By: Steven L. Galetta, MD
Today, approximately 350,000 people are living with multiple sclerosis (MS), an incurable condition that attacks the nervous system. In its early stages, symptoms of multiple sclerosis may come and go in a series of attacks that can be separated by months or even years. Traditionally, a diagnosis of MS is confirmed when a patient has at least two attacks over a period of time. This used to mean that treatment would not start until long after symptoms first appeared. Now, with the aid of brain imaging techniques, some experts are calling for a different approach.
Below, Dr. Steven Galetta, Director of the Multiple Sclerosis Division at the University of Pennsylvania School of Medicine, describes the risks of delaying treatment and the rationale of treating people for MS before a second attack.
What is multiple sclerosis, or MS?
STEVEN GALETTA, MD: MS is an immune attack against the central nervous system, which includes the brain and spinal cord. The immune cells attack the coverings of the "cables" of your brain, which are called "myelin."
These attacks evolve typically over several days and then, often, in the earliest stages of MS, they remit, or go away, and the patient improves over several weeks or months. So the attacks are somewhat unpredictable in the earliest stages of the disease.
MS attacks can affect many areas of the body, and seem random. For instance, the first attack could occur the first time in the optic nerve. The next time, it might affect the spinal cord. Secondary progressive MS is the stage of disease that people begin to experience after several attacks. At this point in the disease, disability starts to develop. The patients may have trouble walking, for instance.
Another form of MS is called primary progressive MS, and is characterized by a steady downhill course. This form of the disease is more rare.
How is MS diagnosed?
We have traditionally required that a patient have two episodes of clinical attacks, separated by a month, before MS can be diagnosed.
But we've come to recognize that patients who have had a single attack with an abnormal MRI scan are at increased risk of multiple sclerosis over both the short- and long-term.
Has this changed the timing of treatment?
MS may be, in the earlier stages, quite silent, and only evident on an MRI scan, so we've pushed the treatment envelope earlier and earlier. In fact, many patients who have had a single attack who have a positive MRI scan are candidates for early therapy.
What's the benefit of starting therapy so early?
The benefit of treating the disease early is to reduce risk of disability. We don't have a lot of long-term studies involving the current available medications for multiple sclerosis, but we feel that there is some evidence to suggest that those patients who start therapy early are doing better than those who have waited, or those who were taking placebo (or inactive substance).
But if you treat people before a solid diagnosis, don't you run the risk of treating people who don't need treatment?
There was a study published in The New England Journal of Medicine this past January that took a long-term look at patients after their first attack, or demyelinating event. Ninety percent of those who had an abnormal MRI at baseline had a second clinical attack within fourteen years. When we combined the number of patients who had a second clinical attack to those who had a new lesion on their MRI, that number rose to 98%.
From that study, we realized that we are going to be treating a very, very small minority of patients who will not go on to have a second attack. I think that study provides powerful information about the rationale for early therapy.
Is it hard to convince a person who has suffered a single attack, and has no symptoms, to start a treatment that has potential side effects?
As a doctor, I have to explain what this first event was, what the prognosis is, and then I have to explain a very complicated regimen that we would have to go through. We would also have to get an MRI scan to see or establish the risk of future events. If they develop a new lesion, or evidence of scarring (sclerosis) in the brain, on an MRI scan, that really tells us that they have multiple sclerosis. Even though the lesion is not associated with a perceivable attack, the MRI is telling us that the disease is active and that this is "multiple", that we do have a second event separated in time by at least one month. And yes, it's a lot for a patient to absorb.
Which treatments should doctors be talking about with patients who may be in early stages of the disease?
We have four drugs that are most often used in this group of patients. They are Avonex, Betaseron, Copaxone and Rebif.
Do you think that every patient with a single event should be treated with one of these drugs?
I think it should be carefully considered, especially in those patients
who have MRI scans that show lesions in other areas.
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