This statement (Time is brain – Time is Brain) is actually the guiding principle of modern stroke care – but it is also increasingly cited in connection with immunotherapy in MS, even though the time spans involved in MS are different.
When I lecture at medical training events or patient events, I often show the diagram pictured above. It visualizes, in my view, the most important principles of modern MS therapy: The natural course of the disease is most effectively modulated when immunotherapy is started as early as possible. Moreover, it is crucial to initiate early therapy optimization in case of suboptimal response to the first chosen therapy.
There is no unlimited time window for this optimization – the “window of opportunity” (best translated into German as “chance”), in which the course of MS can be sustainably influenced, is narrow – every effort should be made to stabilize the disease within the first 5 years after diagnosis. Therefore, the statement “Time is brain” is also justified in the case of MS.
Critics of this concept argue that the idea of optimal MS therapy visualized in the diagram is not underpinned by evidence-based data, but is merely a hypothesis. However, this criticism is no longer tenable in light of a recent study by Brown et al. published in the Journal of the American Medical Association (JAMA. 2019 Jan 15;321(2):175-187). The targeted evaluation of the MS Base Register supports the thesis that early therapy optimization has an impact on the further course of the disease.
MS Base is a global registry that now includes data from more than 40,000 MS patients. Due to this amount of data, it is possible to identify enough patients for certain clinical questions who meet specific criteria and can be compared using statistical methods with regard to their outcome. In the specific case, the authors investigated the proportion of patients who develop secondary chronic progressive MS (SPMS) – the phase of the disease characterized by continuous progression of the disease that should be avoided at all costs – depending on various therapy regimens.
Early initiation of therapy is worthwhile – it has been shown that immunotherapy initiated within the first 5 years after diagnosis results significantly less often in SPMS than if therapy is initiated later, i.e., more than 5 years after diagnosis. Furthermore, it was shown that therapy optimization, i.e., adjusting to more effective MS drugs, within the first 5 years after diagnosis also less often results in a secondary chronic course. In addition, the authors were able to show that patients who are treated with highly effective MS drugs from the outset have a better outcome than those who are initially treated with less potent drugs.
These results are the results of patient groups and not of individual cases, so the result does not mean that every individual with MS should only be treated with highly effective second-line drugs – the disease is too heterogeneous for that and this would not do justice to the many patients who have a mild course of disease.
However, the results clearly indicate that patients whose disease is not adequately controlled and stabilized should be treated as quickly and consistently as possible with highly effective substances within the first 5 years after diagnosis. Because “Time is brain” … .
