Multiple Sclerosis

Misha Pless, MD, BAS

Admittedly, no other subfield in clinical neurology has experienced greater transformation than multiple sclerosis (MS) and neuro-immunology in the past 20 years. Personally witnessing this revolution has been most satisfying and stimulating. Whereas colleagues in other subfields of neurology may sometimes be thinking radically differently about the diseases they treat, no other neurology specialist is actually treating patients fundamentally differently today than three decades ago, when β interferon was first introduced as a therapy for MS. Neurologists are taking care of MS patients with the help of therapies based on increasingly intricate therapeutic algorithms, which translates into better quality of life for countless patients and their families.

Anyone who treats patients with MS will attest to the fact that what is noted in clinical trials, the change in the slope of Kaplan-Meier curves associated with treatment compared with placebo, in effect means our patients are enjoying richer and healthier lives. Patients with MS no longer call the doctor as often with symptoms because relapses are truly less frequent and milder when patients are properly and effectively treated. Hospital length of stay has been shortened, if not made obsolete, not because of external forces, but because patients are doing unquestionably better. Patients with MS are finally living with the idea MS is a chronic but treatable condition, a disease that is controllable, which can even be mastered with the appropriate supports. The idea that MS controls the patient from day 1 of diagnosis is no longer acceptable. As the symbol associated with the diagnosis of MS, the wheelchair is slowly, and thankfully, fading.

This paradigm shift has affected everyone and is the result of enormous efforts, which stem from so many sources, and require massive resources. It has taken the work of thousands of researchers and clinicians, collaboration between clinical trialists and pharmaceutical companies, and most importantly, willingness on the part of affected patients and their families to explore and think ahead. This all translates into an entirely distinctive world in the care of patients with MS today. The MS-specialized neurologist can look forward to being involved in an exhilarating specialty, of truly helping his or her patients enjoy a higher quality of life, but will also be confronted with a highly complex field, which, truth be told, today looks more like oncology or transplant medicine than neurology. As such, any neurologist who wants to practice in a state-of-the-art environment taking care of MS patients has to be prepared to deal with complex pharmaceuticals with potentially complicated side effects. To take care of MS patients, a neurologist needs to master copious amounts of information regarding each specific treatment; be aware of the new treatment algorithms; and be attentive to the side effects of medications, many of which are dangerous or potentially fatal and may even resemble the symptoms of the disease they are treating—this paradox sometimes makes the MS neurologist quite uncomfortable. Thus as someone involved in the care individuals with MS and in training young neurologists, I direct equal effort to the proper understanding of the disease and to the drugs that are used to treat it.

Not a single day goes by that I do not spend time thinking about new developments in the field of MS, the advancements made, and my own MS patients, who have climbed 8,000-m peaks and run marathons. But I am also often worried I might be missing an early progressive multifocal leukoencephalopathy (PML) case, or that a patient on a teratogenic compound might have accidently gotten pregnant. Today, when treating MS one must devise checklists: Think of oneself as an airline pilot who is in the complexity of the cockpit about to fly passengers safely to a destination. Today's neurologist specializing in MS needs support, a team of professionals who help patients—and the doctor—stay safe. Together with the numbers of nurses and medical assistants who keep the patient–doctor relationship dynamic and out of harm's way, an MS Center looks today more like a transplantation or a rheumatology clinic if one judges by the number of infusion units and treatment protocols. And well it should—this is the New Neurology. Nevertheless, practicing solo as a modern MS neurologist has become extraordinarily difficult and not without peril, one of the unforeseen repercussions of such modernity. Without going too far, almost every week there is a new development, which adds greater intricacy to our field. The complexity of interactions and potential side effects associated with the new oral drugs, the possibility of contracting viral infections with drugs hitherto felt to be safe, the chance of a patient contracting PML even with a negative JC virus antibody test, the fear of lowering the threshold for cancerogenesis, are a few of the issues that confer substantial ramifications to our work. However, despite these worries and potential hazards, the horizon in my opinion is brighter than ever for patients with MS. The emerging drugs for the treatment of secondary progressive MS, recent trials with a drug that offers hope for patients with primary progressive MS, new progress in early diagnosis, advancements in the imaging of the disease, neurorehabilitation, and the ever-improving treatment protocols for relapsing disease, are developments that far outweigh some of the mentioned perils.

When Dr. Greer asked me to serve as Guest Editor of this issue, I was thrilled. To be able to contribute to the discipline, albeit in a modest way, by assembling a superb team of specialists, each involved in his or her own way in making MS a curable disease, is truly an honor. Here the authors provide summaries of old and new therapies and clinical manifestations, but also overviews of natural concepts applicable to neurologic care, which have specific importance in MS, such as cognition and neurorehabilitation. Early diagnosis plays a critical role in MS as it has been repeatedly demonstrated that early treatment makes a difference in prognosis, a theme that appears often in this issue. By no means is this issue a comprehensive treatise on MS; it aims to capture some of the critical aspects of MS today. Even so, by the time this issue is published, some of the information included might have become more or less out of date. That is the nature of a rapidly changing field—and that is exactly what makes it exciting for all involved.