Dr. Kathy Costello

Kathy Costello, MS, CRNP

Expert Perspective

 

Multiple Sclerosis: Biomarkers, Treatment, and Depression Management

Headshot
Practice Community
Baltimore, MD
Hospital and Institute Affiliations
National Multiple Sclerosis Society, Johns Hopkins Multiple Sclerosis Center
Number of Patients Seen in a Week
Approximately 6-7 per week
Practice Niche
Adult Multiple Sclerosis

Question

What are the clinical roles for molecular biomarkers in diagnosing and monitoring MS disease progression and treatment response?

Answer

To date, there are no specific biomarkers to make a diagnosis, determine response to medication or predict disease course. The diagnosis of MS is made by putting together multiple pieces of information – including a history of symptoms consistent with MS, a neurological exam with findings referable to the central nervous system, and an MRI of the brain that is consistent with MS. Over the past 30 years, MRI techniques – as well as knowledge of the appearance of MS abnormalities have improved such that MRI has become a very important test to support a diagnosis of MS. Other tests may be used to help determine the diagnosis – such as an analysis of spinal fluid that may show indication of immune system activity in the central nervous system or other tests that measure nerve connections of vision, hearing, and sensation – known as evoked potentials. Finally, excluding other conditions that can mimic MS (and that do have specific tests) must be done. All of this evidence is assembled and help to make or exclude the diagnosis of MS. In terms of monitoring response to a DMT [Disease Modifying Treatment], relapses, progression of symptoms, and MRI findings help determine an optimal or sub-optimal response to any particular DMT. Ideally, having no relapses, no progression, and no new lesions on MRI would be an optimal response.

It is hoped that continued research in this area will lead to the identification of true biomarkers to help make an accurate and timely diagnosis – and biomarkers that will help predict response to medications and predict overall disease course.

Question

How have the newer immunomodulatory agents changed the standard of care? (What do we know about optimal combinations or sequencing of treatments?)

Answer

At this time, there are no standard guidelines or a treatment algorithm to guide treatment with the MS disease modifying treatments (DMTs). The discussion and decision making occur with the person living with MS and his/her provider – and include the goals of treatment, efficacy, side effects, risks, ability to adhere and cost/coverage. There is a large body of evidence that supports early treatment with a DMT, including clinical trial data supporting the use of a DMT in clinically isolated syndrome (the first clinical event with features consistent with MS and not explained by an alternate cause). While not a standard of care, there are many clinicians who favor aggressively treating more aggressive MS (with high level of clinical and MRI activity early in the disease process) with the DMTs considered to be more potent. Overall, having numerous available treatments (with varying mechanisms of action, side effects and risk profiles) may prompt earlier changes in treatments when new disease activity occurs, or when an individual experiences intolerable side effects or is at greater risk for serious side effects.

Question

How should depression be managed among people with MS?

Answer

There is up to a 50% lifetime prevalence of major depression in people diagnosed with multiple sclerosis.1 There is also significant morbidity and mortality associated with untreated depression. Therefore, it is important to identify symptoms of depression early and recommend intervention with a mental health professional. Screening for depression should occur regularly along with other neurological assessments and those screening positive for depression or other mood disorders need referral and follow-up. The National MS Society can help with the identification of mental health providers in a particular area. Management often includes therapy (CBT, psychotherapy or other interventions2) and may also include treatment with an antidepressant medication.

References

1) Boeschoten RE, Braamse AMJ, Beekman ATF, et al. Prevalence of depression and anxiety in multiple sclerosis: a systematic review and meta-analysis. J Neurolog Sci. 2017;372:331-341. doi: 10.1016/j.jns.2016.11.067

Fischer A, Schroder J, Vettorazzi E, et al. An online programme to reduce depression in patients with multiple sclerosis: a randomised controlled trial. Lancet Psychiatr. 2015;2(3):217-223. doi: 10.1016/S2215-0366(14)00049-2