February 1, 2004
Medscape Neurology & Neurosurgery 6(1), 2004
I am treating a 30-year-old woman with a history of optic neuritis 3 years ago. MRI was normal, CSF showed oligoclonal bands. There was no further clinical relapse of any neurologic deficit. MRI follow-up this year showed two T2 and flair-positive lesions without gadolinium uptake in the corpus callosum, which fulfilled McDonald's criteria. Do you see an indication for immune-modulating therapy in this case, and if so, what course would you recommend?
Sybrandus Kreijenveld, MD
Response from Omar Khan, MD
Associate Professor of Neurology and Medical Director, Multiple Sclerosis Clinic, Wayne State University, Detroit, Michigan
I would favor treatment initiation, as it appears that over time the patient has experienced disease evolution into definite MS as defined by the new criteria. While one may argue that the disease is so mild at this time that therapy may not be warranted, it may not be in the patient's interest to wait for the disease to worsen or become moreactive.
Another compromised approach would be to follow the patient clinically (evaluate every 6 months) and repeat another brain MRI in 1 year or sooner. If there are any additional changes, starting therapy would be most reasonable. In any case, my recommendation would be to consider either high dose beta-interferon or glatiramer acetate.
There is no doubt that interferon-beta is an effective choice for early MS. However, in my opinion, glatiramer acetate is better tolerated, which is an important consideration for patients at an early stage of this disease, and is particularly important when accepting the diagnosis and facing the symptoms of the disease are more daunting than ever. For newly diagnosed patients, a therapy with fewer side effects is more likely to lead to long-term compliance compared with a therapy with potentially difficult but manageable side effects.
While one may argue that no trial of glatiramer acetate has been conducted with patients who are experiencing very early symptoms suggestive of MS, a large multicenter study is currently under way with a trial design that is more comprehensive than any other previous trial for this indication. Nevertheless, the case for early treatment with disease-modifying therapies is logical and supported by compelling data.
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Dalton CM, Brex PA, Miszkiel KA, et al. Application of the new McDonald criteria to patients with clinically isolated syndromes suggestive of multiple sclerosis. Ann Neurol. 2002;52:47-53.
Goodin DS, Frohman EM, Garmany GP, et al. Disease modifying therapies in multiple sclerosis: report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology and the MS Council for Clinical Practice Guidelines. Available at: http://www.aan.com/professionals/practice/pdfs/gl0091.pdf Accessed December 30, 2003.
McDonald WI, Compston A, Edan G, et al. Recommended diagnostic criteria for multiple sclerosis: guidelines from the International Panel on the diagnosis of multiple sclerosis. Ann Neurol. 2001;50:121-127.
Ranjeva JP, Pelletier J, Confort-Gouny S, et al. MRI/MRS of corpus callosum in patients with clinically isolated syndrome suggestive of multiple sclerosis. Mult Scler. 2003;9:554-565.
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Disclosure: Dr. Khan has disclosed that he has received grants
for clinical research from Teva Neuroscience, Biogen, Berlex, Schering,
and Elan. He has received grants for educational activities from Teva,
Biogen, Berlex, Serono, Immunex, and Schering. He has also served as an
advisor or consultant for Teva, Berlex, Serono, and Schering.
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