[vc_row][vc_column][vc_column_text]14–17 September 2016, London, UK
These are exciting times in the field of multiple sclerosis (MS) management; the past 5 years have seen an explosion in the number of disease-modifying therapies (DMTs) licensed for the treatment of patients with relapsing–remitting MS (RRMS). Also, some of the original first-line injectable DMTs have now been prescribed for more than 20 years. Accordingly, neurologists have a greater choice of DMTs and a better understanding of their long-term benefits and risks in real-world clinical practice than was the case a few years ago. Following last year’s ECTRIMS congress, in which the first robust evidence of an effect of DMTs on disability progression in patients with primary progressive MS (PPMS) was reported (the phase 3 ORATORIO trial), secondary analyses of data from this trial and reports of DMTs in the same class featured heavily at this year’s meeting. However, the most highly anticipated report this year was that of the phase 3 EXPAND trial, which demonstrated a reduction in disability progression among patients with secondary progressive MS (SPMS). Accordingly, the promise now exists of DMTs becoming available to treat all forms of MS.
Within this landscape, committee President Professor Xavier Montalban set out an aspiration for personalized treatment in MS during the annual ECTRIMS lecture. Treatment decisions in MS have historically involved a degree of trial and error; unlike therapy areas such as oncology, no genetic polymorphisms have yet been identified in MS that are of prognostic value in informing treatment decisions. It is only by understanding the prognosis and personal circumstances of each patient, and informing them of likely side effects and burdens associated with each DMT, that a decision can be reached regarding the most appropriate treatment. Achieving this goal will also necessitate the regulatory freedom to choose the most appropriate therapy rather than reserving treatments for use only when others have failed. Related to this point, new clinical practice guidelines on the pharmacological management of MS are at an advanced stage of development by ECTRIMS and the European Academy of Neurology.
A well-established principle in RRMS is that the sooner treatment begins, the better the outcome for the patient, but this premise rests on diagnosing the disease at an early stage. A number of presentations summarized analyses of factors observed at disease onset that are predictive of conversion to MS and of subsequent disease evolution. Such analyses have also provided insights into the relative real-world efficacy and safety of different DMTs in the very long term. Moreover, the definitions currently used in the diagnosis of MS, the prognostic utility of certain factors (e.g. oligoclonal bands in cerebrospinal fluid) and developments in the measurement of different potentially diagnostic biomarkers (e.g. serum levels of neurofilament light chain) all came under scrutiny.
As well as understanding factors that are likely to predict a particular disease course, it is important to develop measures of disease activity that accurately assess treatment effects and predict long-term outcomes for particular DMTs. Studies increasingly include combination assessments such as the Rio score or ‘no evidence of disease activity’ (NEDA) in order to assess how well patients respond to therapy. Certain presentations examined the predictive power of these measures, the challenges and relevance of incorporating metrics such as changes in brain volume or in retinal nerve fibre layer thickness, and the option of adopting new assessment goals such as ‘minimal evidence of disease activity’ (MEDA). The definitions and components of these combination assessments will evolve, but it seems increasingly likely that clinicians will treat to such targets.
This summary inevitably omits a great many topics explored during this year’s meeting, including developments in imaging, the understanding of underlying disease pathology, the mechanisms of action of different therapies, and of different treatment strategies. However, in terms of disease management, there is no doubt that change has been wrought. This was articulated succinctly by Professor Eva Havrdová, a neurologist with 35 years of experience in treating patients with MS. While recognizing the unfortunate reality that some patients still experience very aggressive disease, she noted, “When I entered the neurology clinic [I saw] a lot of 40-year-old patients lying in bed without the ability to stand or the ability to sit or without the ability to swallow. This [has] changed; you do not see these people anymore.” The next ECTRIMS meeting will be held in conjunction with the partner American committee (ECTRIMS-ACTRIMS, 25–28 October 2017, Paris, France).
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