Dr Belinda Weller is a consultant neurologist in Edinburgh. She tells us how she first came across the idea of early, proactive treatment, and the difference it’s made to how she works with people with MS
I’ve been working in MS for over 10 years. 10 years ago if someone was diagnosed with MS we followed the guidelines: if you’d had two relapses in two years, you had a choice of one of the interferon injectable treatments. Sometimes I would guide people, but in general I let them make the decision. I didn’t think there was a lot of difference between them. So if people had relapses we didn’t have a lot to do really. We didn’t repeat MRI scans and we kept people on the same treatments.
Treating people proactively
The idea of early treatment was really strengthened for me when I was doing a sabbatical in Australia three years ago. I found that neurologists over there were much more assertive in getting people treated, pretty much at the point of diagnosis.
At that point they were just starting to treat people more proactively because they had Gilenya a little bit ahead of the UK. There still were people on the first line treatments like the injectables, but they also got annual MRI scans. And if people had even one or two new lesions the neurologists would advise people to switch to a more effective treatment.
I can’t say that I saw immediate effects of this approach, because I wasn’t there long enough. But if someone had a relapse you could say, “OK, we can put you on a different treatment which might be more effective”. If you have MS I think that’s very reassuring and encouraging.
When I returned to the UK I found people were just starting to talk about proactive and escalating treatment. Because we now had more options, so we could change treatment, rather just switch from one injectable treatment to another. We had Tysabri that you could escalate to, and then a bit later we had Gilenya.
So now if I speak to someone who’s just been diagnosed with MS I say: “We’ve got increasingly effective disease modifying drugs (DMDs) that can keep you from getting any worse. We can’t change things that have already happened, but if we get you onto treatment quickly, our aim is to keep you as well as you are now, indefinitely”.
You still get people who are a bit uncertain about treatments. They’ve heard that they’ve all got bad side effects, or they’re not that effective. So I say to people, “Look, these treatments do make a difference. And there is evidence that treating earlier gives better results. And while you are on your treatment we will try to do regular MRI scans, so we’re checking how your brain is doing, as well as how your doing in our clinical tests”.
How early should people with MS get treatment? That’s a big question. We’re probably a bit slower in the UK, because not everyone is treated after clinically isolated syndrome (CIS).
Not everyone with CIS will go on to get MS. But I think there are cases where we should be treating from the first symptoms. And I think certainly, with people who’ve had two relapses close together, and you’ve made a diagnosis of MS, they should be offered treatment straight away. And I would prefer to offer it then rather than wait.
I don’t think it’s ever too late to begin taking a DMD, unless you are very obviously in the progressive phase. We know that the DMDs probably aren’t helpful then. But if you are still having relapses I think you will benefit from DMDs and they should be offered to you. And if you’re in the progressive phase you should be considered for trials for treatments for progression.
The future of MS treatment
I think the idea of early, monitored treatment is certainly becoming more popular. If you follow MS research, I think the evidence is increasing. Not just starting treatment early, but being ready to switch treatments, and being aware that you don’t just go on how the person is doing in clinical tests, you should be repeating MRI scans.
And we really should be aiming to suppress relapses but also to suppress MS activity in the brain. I know that’s not always possible but at least you should be aiming for that.
I think we’re now beginning to see the benefit of this approach. This is purely anecdotal, but we’re working on the MS-SMART secondary progressive MS (SPMS) study here in Edinburgh, and I was looking through our database for people to take part. I found that we don’t have that many new people with SPMS coming through. There could be a number of reasons for this, but I am hopeful that by treating people early and effectively we are starting to reduce the number of people who are going into the progressive phase.