POOR PROGNOSIS MAY REQUIRE DECISIVE ACTION

  • MS is the leading cause of nontraumatic young-adult neurologic disability1
  • Cumulative effects of disease activity incurred early in the disease course may lead to progressive disease and long-term neurologic damage2-4

Consider independent factors to identify certain patients who may be at increased risk of a poor prognosis5 :

DEMOGRAPHICS

  • Older age at onset (≥40 years old)6-8
  • Race: African American, Hispanic9,10
  • Gender: Male8,9,11
  • Smoker12

CLINICAL

  • High relapse rate in the first 2 years9,11,13
  • Incomplete recovery after relapse9,11
  • Short interval between first and second relapse8,11,13
  • Motor involvement or ataxia in relapse9,11
  • Cognitive impairment13,14
  • Vascular risk factors (eg, diabetes)15
  • Multifocal CIS onset (suggestive of multiple neurologic areas affected by inflammation)5,13

PARACLINICAL

  • Brain stem and/or spinal cord lesions9
  • Presence of contrast-enhancing lesions9,11
  • High T2-lesion load9
  • Chronic T1-hypointense lesions11,16
  • Early brain atrophy11,16
  • Oligoclonal bands in the CSF (eg, IgG, IgM)11,17-19

Currently, there are no DMTs indicated to treat any clinical or paraclinical factors listed above. This includes TYSABRI.

Prompt decision making early in the course of relapsing MS and throughout treatment may affect patient outcomes2,20-22

THERE IS A STRONG CORRELATION BETWEEN MRI LESION LOAD AND THE SEVERITY OF PHYSICAL DISABILITY AT 5 YEARS23

THERE IS A STRONG CORRELATION BETWEEN MRI LESION LOAD AND THE SEVERITY OF PHYSICAL DISABILITY AT 5 YEARS23
THERE IS A STRONG CORRELATION BETWEEN MRI LESION LOAD AND THE SEVERITY OF PHYSICAL DISABILITY AT 5 YEARS23

Adapted from Comi, Clin Ther, 2009; Compston, Lancet, 2008; Fisniku, Brain, 2008; and Trapp, Neuroscientist, 1999.2,24-26
For illustrative purposes only.

There may be a therapeutic window of opportunity in optimizing treatment3,4,27,28

  • The volume and the accumulation of T2 lesions over 2 years were significantly correlated with future physical disability29
  • Brain lesions at baseline were predictive of physical disability status after 10 years30

MRI can help detect subclinical disease2,31,32,a

  • After 1 year of treatment31,32:
    • Relapse-free patients continued to show active disease on MRI and significant risk of worsening physical function
    • Risk of disease progression has been shown to rise as lesion load and relapse rate increase

Consider monitoring for an inadequate response after the first 6 to 12 months of therapy. An inadequate response can be defined by a combination of parameters, which may include31,33-35 :

MRI
ACTIVITY

  • Ongoing disease activity detected by MRI31,35
  • ≥1 Gd+ lesion or new or enlarging T2-hyperintense lesion within 1 year31,33

LEVEL OF PHYSICAL
DISABILITY

  • An increase in EDSS score on new therapy4,33
  • ≥1-point EDSS score increase at
    6 months36

RELAPSE
FREQUENCY

  • Recurring relapse after treatment initiation31,35
  • ≥1 relapse within 1 year4,31

Proportion of patients on first-line therapies with an inadequate response can vary based on criteria used. Some studies prior to 2010 show that up to two-thirds of patients may exhibit an inadequate response after relapsing MS treatment initiation.4,33,37

REAL EXPERIENCES TREATING RMS

Leading physicians discuss the need to monitor disease activity to help guide treatment decisions.

CSF=cerebrospinal fluid; IgG=immunoglobulin G; IgM=immunoglobulin M; DMT=disease-modifying therapy; ARR=annualized relapse rate; EDSS=Expanded Disability Status Scale.