By Bruce A. Cohen, MD, as told to Keri Wiginton 

We know so much more about multiple sclerosis (MS) than we used to. But one important theme is that we’ve become much better at treating the relapsing form of this disease and changing its natural history. That wasn’t the case early in my career. 

I’m old enough to remember when the only thing we could do for someone with MS was help manage their symptoms. Today, if you’re diagnosed with relapsing-remitting MS, there’s a very high chance treatment will help you live a largely normal life. 

But there’s still this idea that MS is a seriously debilitating disease, especially if you don’t know anyone with it. There’s a reason for that. Most of the people I treat don’t go around telling people they’re sick. And if you saw them walking down the street, you’d have no way of knowing.

What’s Changed With Multiple Sclerosis Over the Last 20 Years?

In 2006, the FDA approved natalizumab. That was the first monoclonal antibody used to treat relapsing-remitting MS. It’s a type of disease-modifying therapy (DMT). There’s been an explosion of effective DMTs since then.

There’s no cure for MS. But DMTs can slow or stop damage caused by the disease. And we have evidence they can lower the rate at which people with MS progress to disability. According to some studies, they may even help people with MS live longer.

This treatment breakthrough came from a better understanding of the biology of MS and how the immune system is involved. We no longer focus solely on T cells. 

We use more selective therapies to go after proteins in other parts of the immune system, including B cells and innate immune cells.

We also use more advanced tools to understand MS. We use MRI to get a more detailed look at how the disease affects the brain and spinal cord. These scans can also give us a good idea about whether your treatment is working.

In the future, PET scans may be used to locate MS-related damage better and earlier than we can now. But this is just a research technique at this point.

There isn’t one way to detect MS, and a misdiagnosis isn’t uncommon. But the tools we use to diagnose people now are more sensitive and specific. That includes something called the McDonald criteria. These are agreed-upon expert guidelines. The goal is to diagnose MS faster and accurately according to a set of typical signs and symptoms. 

And we’re starting to find likely biomarkers for MS. Going forward, in addition to imaging, we may be able to use body fluids as another way to diagnose the disease. 

The Importance of Early and Effective Treatment

We know from imaging studies and long-term research that MS is active under the surface. It may cause damage that’s hard for you and your doctor to pick up on at first.

For example, there are studies in which MRI scans are done on a monthly basis in people with relapsing MS. Researchers saw that lesions appear and disappear more frequently than people have symptoms. That tells us the disease is active even though the central nervous system seems to have some functional reserves, especially early in the disease course.

So we know that damage happens early on, even though the tools we use to measure MS activity at the doctor’s office may not be sensitive enough to measure it. And we know that when we treat the disease early and control that activity, we can lessen the number of attacks and symptoms people have later on.

But it’s not just the early part that’s key. The medication you’re on needs to work. The good news is we’re learning more about how to keep an eye on the effectiveness of each therapy, which includes monitoring MS activity with MRI. 

Comprehensive Multiple Sclerosis Care

I think this concept of a comprehensive approach to MS – which includes both the treatment of the immune aspects of the disease as well as the damage caused by MS – has also evolved over the past couple decades.

For example, we’ve gained a great deal of information on symptom management. And we have better treatment for things like bladder dysfunction and mobility issues. There are more options for high-tech orthotics and adaptive devices. And we’re starting to see the benefits of physical activity, including adaptive exercises.

There’s also a greater understanding of the impact of other health issues on disability. That includes tobacco smoking and heart and blood vessel problems. Obesity, metabolic syndrome, and diet may also play a role in the course of the disease.

If you have MS, addressing all these can boost your quality of life and help you keep doing the things you care about. 

What’s Next for Multiple Sclerosis Treatment?

There’s a lot of research interest in Bruton’s tyrosine kinase (BTK) inhibitors. Among other things, these drugs target inflammation caused by B cells. As mentioned earlier, scientists think these immune cells play a big part in the development of MS.

It looks like BTK inhibitors can get into the central nervous system. We need more research, but this kind of treatment could impact things going on inside the brain and spinal cord. Current therapies can’t do that. They mostly act on the whole immune system, affecting cells that circulate in the blood.
If BTK inhibitors work the way scientists think they do, they might help people with progressive MS. But that’s something researchers are still looking into.

We’re also starting to explore therapies that might protect the central nervous system from damage and help make the brain and spinal cord better able to fix themselves. This kind of research is promising, but we don’t have anything that’s been shown to do this yet.

And that leads us to other areas of development, which is the unmet needs of people with progressive MS. I think we’re going to see further evolution of our understanding of this form of the disease. And, potentially and optimistically, some development of therapies to further limit progression.