Tailoring treatment to individual patients is the ultimate goal in the complex decision-making process of managing progressive multiple sclerosis (MS), noted Burcu Zeydan, MD, assistant professor of neurology, assistant professor of radiology, Mayo Clinic.
Tailoring treatment to individual patients is the ultimate goal in the complex decision-making process of managing progressive multiple sclerosis, and this process should include consideration of drug efficacy and safety, as well as modifiable risk factors, noted Burcu Zeydan, MD, assistant professor of neurology, assistant professor of radiology, Mayo Clinic.
What are the treatment options for older patients with multiple sclerosis?
I think this is a very important question. But first of all, I would like to emphasize that the practice will vary from center to center, so we have to be very careful about making blanket statements.
Although the latent observations in MS may have certain implications in patient management, each expert has a different approach. MS is a dynamic continuum of phenotypic phases, and these phases— the relapsing-remitting phase and progressive phase—they are sequential. But they are also overlapping. So, I guess we could say that for those patients who are still transitioning from the relapsing-remitting phase to the progressive phase, we can maintain the DMTs [disease-modifying therapies].
There is always a dilemma in making decisions about treatment discontinuation at an older age, because with aging we know that the relapses and subclinical lesions decrease, the progressive disease course becomes more prominent, and the DMTs lose efficacy. But at the same time, the postrelapse recovery capacity declines. So even a single relapse at an older age may have a critical impact on disability worsening.
Another essential component of patient management is, of course, symptomatic treatment, such as targeting bowel and bladder problems and spasticity. We know that this symptomatic treatment is very important for quality of life in every phase of MS, but it actually becomes even more important during the progressive phase of the disease.
Aging seems to be the ultimate target for prevention of progressive disease course. But in addition to age, there are other useful predictors of evolution to progressive MS, such as being male, having spinal cord lesions, smoking, and being obese. And some of these factors are actually modifiable. Although it is not studied extensively, keeping an active lifestyle and physical therapy seems to be one of the most logical approaches to preserve the CNS [central nervous system] reserve at this time. So, we should not underestimate the value of exercising.
Overall, there seems to be a complex decision-making process regarding the management of patients with MS. Ultimately, the goal should be to make an informed decision tailored for each patient while taking into consideration the aging-related observations in the matter. Including drug efficacy and safety.