Multiple Sclerosis in Practice

An Expert Commentary with Fred D. Lublin, MD, FAAN

A Clinical Context Report

Jointly Sponsored by:

and

Clinical Context: Multiple Sclerosis in Practice

Expert Commentary

This activity is supported in part by an educational grant from Teva Pharmaceuticals

Clinical Context: Multiple Sclerosis in Practice

Expert Commentary

Multiple Sclerosis Clinical Context Series

The goal of this program is to provide up-to-date information and multiple perspectives on the pathogenesis, symptoms, risk factors, and complications of multiple sclerosis as well as current and emerging treatments and best practices in the management of multiple sclerosis.

Multiple Sclerosis Clinical Context Series

Target Audience

Multiple sclerosis physician specialists, community neurologists, advanced practice healthcare professionals, primary care physicians, multiple sclerosis nurse specialists, nurse practitioners, physician assistants, pharmacists and other allied health professionals involved in the care of patients with multiple sclerosis.

Activity Learning Objective

Upon successful completion of this educational program, participants should be able to: l  Review the relevance and significance of the

activity in the broader context of clinical care.

CME Information: Physicians

l  Statement of Accreditation This activity has been planned and implemented in accordance with the Essential Areas and Policies of the Accreditation Council for Continuing Medical Education through the joint sponsorship of the Projects In Knowledge and MedPage Today. Projects In Knowledge is accredited by the ACCME to provide continuing medical education for physicians.

CME Information

l  Credit Designation Projects In Knowledge designates this enduring material for a maximum of 0.5 AMA PRA Category 1 Credits.™ Physicians should claim only the credit commensurate with the extent of their participation in the activity.

CME Information: Physicians

l  Credit for Family Physicians MedPage Today "News-Based CME" has been reviewed and is acceptable for up to 2098 Elective credits by the American Academy of Family Physicians. AAFP accreditation begins January 1, 2013. Term of approval is for one year from this date. Each article is approved for 0.5 Elective credits. Credit may be claimed for one year from the date of each article.

CE Information: Nurses l  Statement of Accreditation

–  Projects In Knowledge, Inc. (PIK) is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.

–  Projects In Knowledge is also an approved provider by the California Board of Registered Nursing, Provider Number CEP-15227.

–  This activity is approved for 0.50 nursing contact hours.

–  There is no fee for this activity.

DISCLAIMER: Accreditation refers to educational content only and does not imply ANCC, CBRN, or PIK endorsement of any commercial product or service.

Fred D. Lublin, MD ,FAAN, Saunders Family Professor of Neurology

Director, The Corinne Goldsmith Dickinson Center for

Multiple Sclerosis Co-Chief Editor, Multiple Sclerosis and Related

Disorders Mount Sinai School of Medicine

New York, NY

Discussant

Disclosure Information Fred D. Lublin, MD, FAAN,

has disclosed the following relevant financial relationships:

Received Research Support: Acorda Therapeutics; Biogen Idec; Celgene; Genzyme; NIH; NMSS; Novartis; sanofi-aventis; Teva Neuroscience

Consulting/Advisory Board/DSMB: Acorda Therapeutics, Actelion; Bayer HealthCare; Biogen Idec; Bristol-Myers Squibb, Xenoport; Celgene;

Coronado Bioscience, Genzyme, MedImmune; EMD Serono; Johnson & Johnson; Novartis; Pfizer; Questcor; Revalesio; Roche, Genentech; Teva

Neuroscience; sanofi-aventis Shareholder: Cognition Pharmaceuticals

This activity may review off-label or investigational information without any recommendation on their use.

Disclosure Information Robert Jasmer, Associate Clinical Professor of Medicine, University of California San Francisco; John Gever; and Dorothy Caputo, MA, BSN, RN, Nurse Planner, have disclosed that they have no relevant financial relationships or conflicts of interest with commercial interests related directly or indirectly to this educational activity.

The staffs of Projects In Knowledge and MedPage Today have no relevant financial relationships or conflicts of interest with commercial interests related directly or indirectly to this educational activity.

MS Classifications: Introduction

l  Current major MS classifications: –  Relapsing-remitting –  Secondary progressive –  Primary progressive –  Progressive-relapsing

l  Represent clinical phenotypes, not underlying biology

l  NMSS/ECTRIMS committee to reexamine system

MS Classifications: Problems

l  Failed to take into account clinical and radiologic isolated syndromes

l  Different MRI findings in subgroups of patients within classifications

l  Levels of axon loss, neuron loss, demyelination are not accounted for

Toward a New MS Classification System

l  May add specifiers to major types l  E.g., “RRMS stable” for patients with

relapsing-remitting MS but free of disease activity

l  Would be helpful in clinical trials where homogeneous patient samples are desired

Clinical Impact

l  May guide therapy, as evidence base accumulates to identify subtypes with differential responses to standard treatments

l  Recent trials (e.g., CombiRx) may supply much of the needed data

Clinical Impact (cont’d)

l  Current research may help pinpoint when RRMS patients transition to secondary progressive disease

l  Could trigger change in therapy if this were well defined

The Near Future

l  Examining data from recent studies and those now ongoing

l  Identifying additional research needs l  Securing funding for new studies when

necessary l  Educating the MS community

Summary

l  Recognize that current MS classifications are clinical phenotypes that do not take account of differences among patients in underlying biology

l  Understand that MRI findings and other biomarkers may be useful in establishing additional specifiers or subtypes within major MS classifications

l  Appreciate that a biologically based taxonomy of MS will improve research and eventually patient care