More Than Just Relapses and Remissions
Hosted by: David R. Marks, MD, WNBC, New York
Frederick Munschauer, MD
State University of New York, Buffalo
Jeffrey Greenstein, MD
Temple University School of Medicine, PA
MS is considered a relapsing/remitting disease, which means its symptoms come and go in waves. But itís important to realize that even when your symptoms arenít acting up, the disease may still be progressing, and that stopping your medication is usually not a good idea. Join our panelists as they discuss the "insidious progression" of MS and various studies that have been done on it.
DAVID R. MARKS, MD: Hi, and welcome to our webcast. I'm Dr. David Marks. MS is considered a relapsing-remitting disease, which means its symptoms come and go in waves. But it's important to realize that even when your symptoms aren't acting up, the disease may still be progressing and that stopping your medication is usually not a good idea.
Here to discuss what's called "the insidious progression of MS" are two experts. First is Dr. Jeffrey Greenstein. He's a neurologist from Temple University. Welcome. And to his left is another neurologist Dr. Rick Munschauer. He's from the University of New York at Buffalo. Thanks for being here.
DR. FREDERICK MUNSCHAUER: Thank you David.
DAVID R. MARKS, MD: Now, relapsing-remitting does not necessarily mean that the disease doesn't keep going. Why is that?
DR. FREDERICK MUNSCHAUER: That's very true, David. Certainly, the majority of people with multiple sclerosis experience the disease as a series of attacks where they'll have some difficulty with sensation or coordination or vision or balance, and then they heal. There may be weeks or months before another attack comes.
One of the major changes in our thinking about multiple sclerosis is that the disease is really quite more active than what we see clinically. I think our best insight to that has been a series of new studies where people have MRI scans of their head done at very frequent intervals, and we find new areas of inflammation coming and going in people without clinical attacks, sometimes as many as 10 new spots on the MRI for every one major clinical attack. So the disease is more active than just exacerbations.
DAVID R. MARKS, MD: Jeff, why the disparity between the MRI findings and the symptomatology?
DR. JEFFREY GREENSTEIN: We think that part of the explanation for this is that eloquent areas in the brain are not always affected by what's going on. For example, an area that might cause a clinical problem might cause weakness and be very apparent, but an area that may be involved with cognitive function may not be as readily apparent. Also, there may be some effect of summations, so that you have to have a repeat episode or repetitive episodes occur before the symptom actually becomes manifest. These things might explain why there can be disease activity going on in the brain without it being apparent to the person who actually has the disease.
DAVID R. MARKS, MD: But it's still going on.
DR. JEFFREY GREENSTEIN: It's still going on.
DAVID R. MARKS, MD: What role does atrophy in the brain play in this disease?
DR. FREDERICK MUNSCHAUER: We feel that with continuous inflammation over time, and maybe at some periods of time the inflammation may be more intense, and may be more intense in one area of the brain than in the other. But over time, with multiple episodes of inflammation, it's possible to lose actual tissue of the brain. You can lose the myelin sheath around nerves, and there's now emerging evidence that not only can the myeline sheath be injured, but the actual nerve itself -- the wire that we think of as nerves -- can become broken and become transected. Over time, then, there is a loss of brain volume, and we can see that on MRI as what physicians refer to as atrophy.
DAVID R. MARKS, MD: If there is this constant progression of MS, how do we define a relapse?
DR. JEFFREY GREENSTEIN: We still define a relapse as something that actually occurs that is evident to a patient. For example, a period of time where there may be weakness or loss of motor function or loss of motor control and so on, and the classic definition still is a clinical definition that has to occur in someone and has to last for more than one or two days. We still rely on that, although we can correlate that very often with inflammation and activity going on on the MRI.
DAVID R. MARKS, MD: Some patients with the relapsing-remitting form can change into the progressive form. How do you relate this to the findings on MRI?
DR. FREDERICK MUNSCHAUER: It's very true. While some 80% of people start out with attacks and remissions called relapsing multiple sclerosis, about half convert to what we call secondarily progressive MS 10 years into their illness. So the exacerbations seem to die down. They don't have the sudden attacks. But what replaces it is maybe a slow, progressive loss of neurologic function, where they become more impaired as time goes by. It may be quite slow, and it may sometimes be not so slow. So we really think of it as a spectrum. There is inflammation that occurs almost continuously in multiple sclerosis. Early on in the course of the disease, it's attacks followed by remissions, but then a decade or so into the illness, there is a progressive loss of neurologic function, and we need to treat early. Just because you're not having an attack doesn't mean that there isn't damage being done. As Jeff was saying, it's the summation of all these inflammations over decades that results in the kinds of long-term physical impairments that we really want to prevent by treating early, before, if you will, the house has burned down.
DAVID R. MARKS, MD: I don't want to end on a depressing note like that, so just tell me what kind of hope you can offer for MS patients who have this kind of progressive picture.
DR. JEFFREY GREENSTEIN: I think we have treatments available at this point that have clearly been shown to help prevent the development of the progression of MS, and I think it's important to emphasize Rick's comments, that early treatment and treatment with appropriate medications is really the way to go in MS. The studies have shown very clearly that the outcomes are better for people who are on treatment. A lot of what we've said really relates to someone who's not on treatment. The course of the disease can be changed, and early and effective treatment is really, I think, the important thing for someone to take home.
DAVID R. MARKS, MD: A good note to end it on. Thank you both for being here.
DR. JEFFREY GREENSTEIN: Thank you.
DAVID R. MARKS, MD: Thank you for joining our webcast. I'm
Dr. David Marks. Goodbye.
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