Benjamin Segal, MD, tells Kara Mayer Robinson
We’ve come a long way in treating multiple sclerosis — it’s one of the greatest success stories in medicine. Over the past 20 years, there has been a drug revolution that alters the course of disease, especially relapsing-remitting multiple sclerosis (RRMS).
Back when I was in training, we had no drugs that could change MS prognosis or prevent flare-ups. The only thing we have is steroids. We give them to people during severe attacks to speed recovery. But there is nothing we can do to lower someone’s chances of developing the disease. We also cannot prevent future attacks, delay disability or lessen its severity.
There are now more than 15 FDA-approved drugs that can do this. They include vaccines, pills, and IV fluids that you can give yourself. But they vary in effectiveness and side effects. And we have no way of predicting which patient will respond best to which drug.
MS specialists are now aiming for what we call “disease-free activity.” This means no relapses, no new lesions, and no ongoing disability. For many patients, we can do this, especially those with RRMS.
The way we look at secondary progressive multiple sclerosis (SPMS) has also changed. In the past few years, three drugs have been approved for RRMS and SPMS. Prior to this, there were no drugs approved for SPMS other than a very potent chemotherapy that we no longer use.
We now have evidence that early treatment, especially with certain drugs, may delay the conversion of RRMS to SPMS. In some cases, patients do not decline gradually over decades.
what’s on the horizon
Many new therapies are being investigated to further advance MS treatment. Two important areas of research are how to promote repair in multiple sclerosis and how to treat progressive multiple sclerosis.
Remyelination and Repair
In people with MS, myelin is destroyed, which causes many symptoms. Researchers are looking at different strategies to help the body form new myelin, the protective coating around nerves.
Several clinical trials target molecules that normally inhibit myelin growth. Researchers are now studying the protective or pro-regenerative parts of the immune system, which we can manipulate to protect damaged neurons and stimulate the growth of new fibers.
My group at Ohio State University just published a paper in which we found an immune cell that rescues damaged nerve cells from dying. It also stimulates regeneration of nerve fibers. Not only does it stop further damage to the central nervous system, it reverses the damage and restores function.
Treating Secondary Progressive Multiple Sclerosis
We’ve made progress with drug treatments for SPMS, but more work remains to be done.
Data suggest that three drugs recently approved for SPMS are effective in a subset of young adults who still have new inflammatory lesions. But they’re less likely to help those who get sicker. So the task is to find a cure for these people.
Some pills in trials are showing promise. One of these suppresses immune cells normally found in the brain and spinal cord. It prevents the body from activating them. In a recent phase II trial, it slowed the progression of disability in people with inactive, progressive forms of multiple sclerosis.
Find the Right Treatment for Everyone
Currently, we cannot predict which patient will respond best to which drug. But there is a lot of ongoing research that can predict which drugs will work best for a particular individual.
Researchers are also looking for biomarkers to develop blood tests that might tell us whether someone is more likely to respond to one drug than another.
Vitamin D, Antioxidants, and the Gut Microbiome
Some research suggests that very low levels of vitamin D can increase your chances of developing MS. There are now studies looking to see if boosting vitamin D levels through additional supplements can suppress new attacks or new lesions in people who already have vitamin D.
There are also studies that look at the gut microbiome and whether you can better manage MS by changing the bacteria in your gut.
The jury is still out, but researchers are investigating whether certain antioxidants might change the treatment or management of MS. One is called lipoic acid. Some studies suggest it may slow the loss of brain tissue in MS patients. Future research may look at lipoic acid and other antioxidants in more detail.
A New Way to Manage Symptoms
One of the most common and difficult-to-manage symptoms of MS is fatigue. There are studies on medication and cognitive rehabilitation therapy for it. There is also a lot of research into improving prosthetics and robotics to help people with MS function better.
early aggressive treatment
Now that we have powerful drugs for multiple sclerosis, there is a debate about whether it is better to start early on with aggressive drugs, or to start with less effective drugs and then step up (escalate) to more effective drugs.
A recent study showed that people who started on higher potency medication were less likely to transition to SPMS after a few years. New research comparing aggressive early treatment to escalating treatment may help us learn more.
Many of my MS patients are now living full lives. I have seen people who have had no relapses and no new lesions for 2 years. No one will know they have MS.
It was a completely different situation than my residency. Then, most of the people we see continue to need assistive devices and have to stop working.
Healing is hard to predict. We are more likely to find treatments that help slow disease relapses and possibly stop disease progression altogether. Healing may take longer.