More than 260 doctors and nurses from around the world attended a live educational conference in Dubai, UAE, in May 2014. The exciting programme organised by David Bates (UK) comprised three plenary sessions, workshops, and a round table session. Delegates completed surveys before, during, and after the meeting to assess their learning.
In the first plenary session, international experts presented the latest epidemiological and genetic research in multiple sclerosis (MS), and looked at recent developments in the understanding of MS pathogenesis. MS is driven by genes related to immune system pathways, and recently-identified genes can explain 28% of the disease’s heritability. There are also 110 established MS risk variants outside the HLA region, and other low frequency and rare variants are expected to be discovered.
Trying to work out what activates the immune system in MS has long been a burning question for researchers, but the latest research suggests that there is a complex interplay between genes and the environment at work, and that no single factor may be responsible. Recent studies have shown an increase in the female:male ratio of MS cases, highlighting the need to focus future studies on lifestyle changes among women, such as smoking, obesity and birth control.
MRI studies have given us new insights into the pathogenesis of MS by identifying cortical lesions as potential biomarkers of cognitive and neurologic disability. Studies on optimising the use of neurophysiological techniques, particularly evoked potentials (EPs), show promise for identification of patients who are more likely to develop future disability and who need intensive monitoring and treatment. Visual evoked potentials (VEPs) are usually absent in neuromyelitis optica (NMO) with positivity for antibodies against aquaporin. VEPs are less sensitive as an indicator in clinical isolated syndrome (CIS), but subclinical motor evoked potential (MEP) abnormalities may positively predict future motor function involvement. In fact, data suggest that MEPs may predict disability at 2 years in relapsing-remitting MS (RRMS) with 80% accuracy. Optic coherence tomography (OCT) has also emerged as a reliable tool for diagnosis and monitoring of axonal loss after an episode of optic neuritis.
The conference focus moved towards the clinical management of patients with MS, especially how to identify those with poor prognosis and how to optimise their treatment
Approaches to MS treatment over the years are evolving – traditionally, the goals for management of MS have been to reduce disease burden, slow disability progression and suppress relapses. Today, doctors can think in terms of stopping progression, ending relapses and improving cognition and quality of life for their patients. Indeed, patient management approaches have evolved so far that today, doctors are aiming for ‘no evident disease activity’ (NEDA) for their patients and clinical studies now include NEDA as a primary endpoint when assessing the efficacy of new drugs.
Treating to target requires individualised planning with each patient, but a significant proportion will achieve remission up to 40% over 2 years with currently-available drugs. Predicting treatment response is an important part of this process, and delegates heard how important it was not only to set a treatment goal for the patient, but also to have monitoring procedures in place.
This year, the thorny issue of when to initiate treatment was discussed in a workshop and also the topic of a lively debate. Giancarlo Comi (Italy) urged those treating MS patients to start treating immediately, while Aksel Siva (Turkey) made a compelling case to ‘wait and see’. Trial data suggests that treatments for MS are more effective in the relapsing remitting phase than in progressive phase of disease. However, neuroradiological examinations are now detecting increased numbers of patients with radiologically isolated syndrome, but many of these will not go on to develop MS so early treatment may actually cause harm.
The surveys undertaken both before and during the meeting showed that the majority of respondents felt that early treatment can delay relapses, disability, and brain volume loss in the long term, and the ‘wait and see’ argument did not seem to sway their beliefs.
Also debating were Nicola De Stefano (Italy) and Vittorio Martinelli (Italy), who explored MRI versus clinical response to assess treatment failure. Arguing the case for MRI, Professor De Stefano highlighted the importance of MRI assessment of lesions and brain atrophy to predict prognosis, as well as its key role in the recently-developed RIO score to predict response to treatment. Even when clinical signs are absent, MRI can detect brain damage. Professor Martinelli however argued that MRI studies are not fully objective and vary with technique, while clinical evaluation remains the only way of diagnosing and monitoring the many different forms of MS and CIS. As discussed in one of the workshops, clinical evaluation and MRI studies together should help neurologists make the right decision.
The shift in approach towards personalized medicine has been an important theme at this year’s conference, with an ultimate goal to individualise treatment based on the projected disease course. This requires risk forecasts for individual patients, incorporating not only future clinical aspects of the disease (such as cognitive impairment), but also genetic, immunological, neurophysiological and radiological findings. Response to treatment varies hugely among patients, so a means of predicting that response is needed in order to optimise patient management. The Bayesian Risk Estimate for Multiple Sclerosis (BREMS) was discussed as an important tool for predicting the course of the disease and to predict poor outcomes at an early stage, particularly when assessing and comparing the effects of disease-modifying drugs.
Sharing treatment decisions with patients and relatives is important to obtain their commitment to treatment. Adherence to treatment is vitally important, so any side effects of treatment the patient experiences should be managed as soon as they appear.
A roundtable discussion was chaired by Professors Raed Alroughani (Kuwait), David Bates (UK), and Bassem Yamout (Lebanon) to take an in-depth look at the way patients perceive their disease and how they report outcomes. This fascinating session concluded that Patient Reported Outcomes should be incorporated as endpoints in future clinical trials, and that this would increase patient engagement and adherence to treatment.