Dr Mark Freedman Outlines the Precision Decision in Multiple Sclerosis Treatments

There are a lot of factors that should be considered when choosing a therapy for a patient with multiple sclerosis, including the patient profile, the patient’s lifestyle, and the efficacy of the therapy, said Mark Freedman, MD, MSc, professor of medicine in neurology at the University of Ottawa, director of the Multiple Sclerosis Research Unit, at Ottawa Hospital-General Campus, and senior scientists in the neuroscience program at Ottawa Hospital Research Institute.

How has precision medicine allowed providers to refine the management of multiple sclerosis?
We’re all talking a little bit more about precision medicine because we feel it’s very important to not just roll the dice, roll the pen and pick a therapy you think might work. There’s a way of choosing therapy today that may be best for that particular patient and I identified 3 different foci that one needs to look at.

The profile of the patient of course. Being able to pick out those patients who probably warrant a more aggressive approach from those that do not. Then we have an array of drugs. What are we going to choose? Because there are several high efficacy therapies that might be appropriate for that type of individual. Then you have to look at the properties of the therapy, how it’s going to be given, what the potential side effects are. And in that particular individual, for instance, if they happen to be a diabetic, you might not choose a drug like fingolimod just because you’re liable to get more into trouble.

So, being able to tailor that and choose amongst the therapies that you’ve identified is, well, this is going to be a higher efficacy therapy; you might want to go for one of the new immuno-reconstitution treatments, because in that particular patient’s profile a couple of years might be enough for us to sustain effect and that’s going to be good for their lifestyle, which is the third part, is the patient.

If this is somebody who is here temporarily on a job or maybe at school and is going to finish their degree in 2 years and you’re putting them into a therapy that requires very, very strict 4-year monitoring, monthly, and there is such a drug—that might not be such a good choice, because you’re only going to get them for 2 years and then what are you going to do? They may want to travel, extensively, to places that maybe some people don’t want to go that exposes them to bugs and things we would normally not see in North America. They’re going to need vaccinations. Is this drug going to compromise their ability to get those vaccines? So, travel. Planned pregnancies. These are all important questions, but that has nothing to do with the disease, nothing to do with the drug. It has to do with the patient.

And now, the precision would be: are we profiling the right disease for this patient? Are we picking the right drug that will help identify the needs of that particular disease? And is this going to work? Is this patient actually going to take the therapy, tolerate the therapy, and stick with the monitoring? Those are what goes into the precision decision.
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