Identifying Secondary Progressive Multiple Sclerosis - Episode 5
Peter L. Salgo, MD: Let me become a bit recursive here and ask the obvious question, which is, so what? If we can’t affect the course of the disease—and we’re going to discuss whether we can or not—then what difference does it make from a payer’s perspective to establish the diagnosis?
Maria Lopes, MD, MS: Well, think about the course. You have Lyme disease, and you’ve been misdiagnosed with MS [multiple sclerosis]. You miss the opportunity to actually treat and potentially cure that because you’ve missed the diagnosis. And now you’re on a disease-modifying therapy and agents you really don’t need, which may actually make Lyme disease worse and progress. Given the consequences it all hinges on, let’s make sure we have confirmation of the diagnosis, and then appropriate therapy follows.
Thomas P. Leist, MD, PhD: Beyond the treatment, we could also bring NMO, neuromyelitis optica, where obviously MS medications may be in part harmful for some MS patients. Patients make life choices if they are diagnosed with multiple sclerosis. They may not have children. They may do things. They may not go for a promotion at their job because of fear of failing. There are many different issues. I would like to come back to 1 point we glossed over. We said CT [computed tomography] is useless.
Peter L. Salgo, MD: Dr Lopes said CT is useless. Dr Coyle said CT is useless.
Thomas P. Leist, MD, PhD: I’m not going to argue for CT, but I’m going to argue for MRIs [magnetic resonance imaging tests] that are properly done: open, scanned, upright scanned. Low-field MRIs are inherently useless. I would like to make a little patch for the Consortium of MS Centers minimal criteria of what an MRI should be. Because very often we look at MRIs that are short of a Rorschach test and could be anything. And so a quality MRI is like a lumbar puncture that is done in the proper way, a work-up that is done in the proper way is an integral part of the start.
Peter L. Salgo, MD: No test is as useless as the test that doesn’t, by design, tell you what you expect it to tell you. Right? In other words, if you do an open MRI—if I understand you—or a standing-up MRI with insufficient Tesla, and it tells you 1 thing, throw it away, right? It gives you a false sense of security.
Thomas P. Leist, MD, PhD: But then the patient had an MRI and may not be eligible to get another MRI.
Peter L. Salgo, MD: Right. You want her to disallow the inappropriate MRIs and give you the money for the right ones.
Maria Lopes, MD, MS: Well, I think this speaks of standardization, and I think that’s what Dr. Leist and Dr. Coyle are outlining.
Peter L. Salgo, MD: Sure.
Maria Lopes, MD, MS: And as a payer, I’m comforted by a degree of standardization that gets everyone to a higher level, and confirmation of diagnosis is the beginning.
Peter L. Salgo, MD: All right. Well, with all that, is it worth diagnosing MS early? Let’s just put a button on this. Yes? No?
Maria Lopes, MD, MS: I think so. Obviously, isn’t that the point? With disease-modifying treatments, you would hope that you’d get to these patients early to have a significant impact on that journey.
Patricia K. Coyle, MD, FAAN, FANA: You have accumulating data that early treatment are key to decrease late disability. Absolutely all the studies are showing an early treated group is doing better, and you probably have a window of opportunity ideally to treat within 6 months of the first attack to really maximize prevention of future disability. Early treatment, in my opinion, is key.
Peter L. Salgo, MD: This is an answer that is very much of the 21st century. When I went to medical school, that was the debate: why even make the diagnosis? There’s nothing we can do for it.
Thomas P. Leist, MD, PhD: Merritt’s Neurology says one shouldn’t burden the patient with the diagnosis of multiple sclerosis.
Peter L. Salgo, MD: Exactly what I heard.
Thomas P. Leist, MD, PhD: Because there is nothing to be done. I sometimes think that as neurologists we need to look outside the field and go, for example, to rheumatology, where it says treatment to radiographically silent RA, rheumatoid arthritis, is indicated in a patient with rheumatoid arthritis. So what’s good for the joint is probably also good for the brain.