Sunday, 21 September 2014

FW: [Multiple Sclerosis Research] New comment on Treat-2-Target: NEDA (no evidence of disease activ....

Anonymous has left a new comment on your post "Treat-2-Target: NEDA (no evidence of disease activ...":

In general, I am very happy with the new concept of treating with the goal of NEDA, and think that I would want that for my family member or friend with MS.
However, treating MS is different from treating those with RA, and there are reasons why one might choose not to be overly aggressive at first.
1. MS patients tend to be younger, and most often are women who may wish to have children in the future. Using some of the present DMT drugs in those young people would cause concern for long-term harm.
2. Many people with MS can and have achieved NEDA for many years while taking some of the older "less aggressive" injectable DMTs which do not have major safety concerns.
3. A personal comment regarding rheumatologists vs. neurologists: my mother has RA, was treated with methotrexate in her early 80's although her pain responded well to agents such as naproxen. After about one year of methotrexate, she developed mycobacterium avium intracellulare, most likely a consequence of immunosuppression by methotrexate. She underwent 18 months of triple dose antibiotics (which left her feeling chronically nauseated) and of course stopped the methotrexate before her MAI came under control, but it will never be cured and she must now use oxygen (she was not a smoker). The point is that some stronger agents have more potential for harm, and this possibility of harming versus helping a patient must always be considered.

Posted by Anonymous to Multiple Sclerosis Research at Sunday, September 21, 2014 9:18:00 pm

8 comments:

  1. TeamG reactions to this comment?

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    1. profG posted this so I'll let him give his reasoning.

      you can replace a joint you cant replace a brain

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  2. If you don't believe first line injectables have any effect on atrophy, why would you put a patient on one? I think you are doing a complete 180 from what you have conveyed in the past.

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    1. Re: "If you don't believe first line injectables have any effect on atrophy, why would you put a patient on one? I think you are doing a complete 180 from what you have conveyed in the past."

      On average they don't have an effect; hidden in the average are responder and non-responders. It is all about monitoring and getting the non-responders on to a more effective therapies. Some patients with MS prefer to start slow and be escalated if the treatment fails them other prefer to go for higher efficacy drugs from the start. It is all about patient-choice; i.e. informed patient choice.

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    2. Re; "If you don't believe first line injectables have any effect on atrophy..."

      I general we don't treat, or not, treat on beliefs. We like to think our decisions/recommendations are evidence-based. if they are not evidence-based they are usually based on a strong scientific rationale that can be tested.

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    3. "However, treating MS is different from treating those with RA, and there are reasons why one might choose not to be overly aggressive at first." The comment above echoes what Dr. Kapoor stated in the Burning debate with Dr. Vollmer. It seems that the therapy should be tailored to the individual but without reliable biomarkers, other than MRI, this seems like a crap shoot.

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    4. Re: " It seems that the therapy should be tailored to the individual but without reliable biomarkers, other than MRI, this seems like a crap shoot."

      Not really; T2 lesions (focal inflammatory lesions) and brain atrophy in year 2 (neurodegeneration) explain 75% of the variance it relation to disability progression. In terms of biological prediction this is pretty good. What it is telling us if you DMT is not stopping new T2 lesions and normalising brain atrophy after year 1 you are not going to do well.

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    5. This is good news....MRI measures of brain atrophy and lesion load during first two years of initiation of a DMT irregardless of clinical progression as standard of care protocol. I hope neuros get the memo:-).

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