Finally back in person! After the meeting of the European Committee for Therapy and Research in Multiple Sclerosis (ECTRIMS) was held virtually due to the pandemic over the last two years, MS experts from all over the world have now met again – at this most important clinical-scientific MS conference with more than 7000 participants – from 26.10. – 28.10.2022 in Amsterdam. Therefore, I was happy to make my way to Amsterdam – especially to take the opportunity to meet many colleagues in person again. In addition, the meeting provided a very good overview of the currently important topics and discussions around multiple sclerosis. I would like to share this with you (as in previous years) and will report on the – from my point of view – important topics.
Highly Effective Multiple Sclerosis Therapies
A focus of the first day was dealing with highly effective MS therapies. It has now been shown using registry data that early treatment with highly effective therapies can significantly delay disease progression. Therefore, it is a legitimate question whether many more MS patients would benefit if highly effective therapies were used consistently from the beginning instead of slowly escalating to highly effective therapy concepts during the course of the disease.
Under the catchphrase “Flipping the Pyramid” – i.e., reversing the therapy strategy and starting directly with highly effective therapies after diagnosis, instead of starting primarily with moderately effective therapies and escalating only if necessary – Gavin Giovannoni (London) gave a very pointed lecture and argued that neurologists are gambling with their patients’ health if they withhold highly effective therapies (for too long).
Even though such a demand still provokes contradiction, the other speakers in this session also pointed out that prognostically unfavorable factors (such as a high lesion load in MRI or clinical involvement of the brain stem or spinal cord) should influence the choice of therapy with regard to highly effective therapies. In addition, Dalia Rotstein (Toronto) pointed out in her lecture that early and regular monitoring after therapy initiation is necessary to quickly recognize “under-treatment” and make an adjustment to a more potent medication. An MRI examination should be performed about 6 months after the start of therapy and if control of inflammatory activity is lacking within 6 – 12 months, a switch to a more potent preparation should be made. Therefore, sufficient time should also be planned from the start for preparing a therapy change. This includes sufficient vaccination prophylaxis or normalization of laboratory values (especially lymphocyte counts). Even though many neurologists in practice are still rather reluctant to use highly effective therapies at the beginning of MS, a paradigm shift is emerging in light of the discussions at this year’s ECTRIMS.
Gavin Giovannoni (London) also underlines his call for a paradigm shift with the demand for an evaluation of therapy success. One should not only look at motor functions, but also at “brain health” (Brain Health) as a whole. By this he means abilities such as cognition and mental performance. These functions are often impaired in MS patients and we often watch helplessly as patients increasingly suffer from fatigue or can no longer cope at work, but are otherwise physically intact. For him, the claim of preserving brain health justifies the earliest possible use of highly effective therapies.
Against this background, it was interesting to hear what Brenda Banwell (Philadelphia), a renowned expert for pediatric MS, reported about the peculiarities of pediatric MS in the context of the ECTRIMS lecture. Children often have highly inflammatory manifestations of the disease. This means that the MRI images of children and adolescents show a significantly higher number of MRI lesions at initial diagnosis compared to adults. Despite this high inflammatory load, children and adolescents (probably due to the plasticity of the young brain) compensate for this situation very well. According to Brenda Banwell, the disease is hardly noticeable from the outside in children and adolescents affected by MS. However, if you look closer and assess the brain development and school performance of the affected children and adolescents, the picture is absolutely catastrophic. The cognitive performances are highly significantly different from healthy children/adolescents of the same age. Pediatricians are therefore forced to keep an eye on the “brain health” with a view to the future of the adolescents. And here – according to Brenda Banwell – the introduction of highly effective therapies for children (among other things due to the very successful PARADIGMS study with Fingolimod, see DocBlog “MS in children (2) – Therapy) was a real game changer. Not only because of the more pleasant oral intake, but also because of the significantly better efficacy on inflammation. In light of the fact that it is now also clear that the diagnostic criteria developed for adults are also valid for children, the findings of pediatric MS also support the early and consistent highly effective therapy of adults with MS.
Against this background, from my point of view there are hardly any more sensible arguments to withhold highly effective therapy from the vast majority of MS patients at diagnosis.
