Progress in Multiple Sclerosis-ECTRIMS 2013
Andrew Wilner, MD, Neurology, 10:08AM Oct 8, 2013
I’ve just returned from the 29th European Committee for Treatment and Research in Multiple Sclerosis (ECTRIMS) meeting in Copenhagen, Denmark, and learned that advances in the understanding and treatment of multiple sclerosis (MS) continue at a dizzying pace. Patients now have the option of injectable therapy with interferons (Avonex, Betaseron, Extavia, or Rebif), glatiramer acetate (Copaxone), three different oral drugs [(dimethyl fumarate (Tecfidera), fingolimod (Gilenya), teriflunomide (Aubagio)], and an infusion therapy, natalizumab (Tysabri). Alemtuzumab (Campath, Lemtrada), a humanized monoclonal antibody that targets CD52 on lymphocytes and monocytes has received approval in Europe. Barring regulatory snafus at the U.S. Food and Drug Administration, alemtuzumab will soon become available in the US. In addition, second generation orals are already in development.
Refining Standard Treatment
Technological advances are making older treatments safer and more convenient. JC virus screening and perhaps other types of testing such as L-Selectin (CD62L) levels, may circumvent the knotty problem of progressive multifocal leukoencephalopathy associated with natalizumab, vastly improving this drug's safety. First year results from the ADVANCE study suggest that peginterferon beta-1a may allow bimonthly injections, likely to dramatically improve patient acceptance. Autoinjectors for interferons have been modified for ease of use, and at least one injector has the ability to store data to assist with assessing compliance.
Improvements in Imaging and Understanding
Ultra-high field 7.0 Tesla magnets provide higher resolution images of grey and white matter and improved spectroscopy that are enabling additional insights into MS pathophysiology. Optical coherence tomography (OCT) allows a noninvasive look into the integrity of the retinal nerve fiber layer of the optic nerve and may have some use as a surrogate marker of disease progression. Advances in neuroimmunology and genetics are propelling our understanding of MS towards the day when designer drugs may completely eliminate symptoms and progression.
I’ve had the opportunity to attend ECTRIMS meetings for the last several years. (See articles here, here and here.) ECTRIMS 2013 had approximately 7,000 attendees and over 1,000 scientific presentations in contrast to ECTRIMS 2003, which had only 3,000 delegates and a mere 500 presentations. The first ECTRIMS meeting, in 1982, just over 30 years ago, had only 50 attendees.
A New Paradigm
Residents of my era were admonished by their attendings to “know the literature.” One was expected to recite results from important reports in the New England Journal of Medicine, Neurology, or Annals of Neurology on rounds. Even 25 years ago it was a daunting task, but seemed achievable if only one was dedicated enough. Today the training paradigm has distinctly changed. I had the opportunity to speak to an Oxford medical student and a resident, both of whom presented papers at the prestigious late-breaking news session on the last morning of the ECTRIMS Congress. I was struck by their ready acknowledgement that there was clearly too much to learn, even in their narrow research areas. One can only forge ahead, study the papers most relevant to one’s research, and proceed knowing that there is a huge amount of information that one will inadvertently overlook. Today's students are never more than an arm's reach away from their smartphones or computers and the world's largest digital libraries. Constant internet access has replaced dusty library stacks. (At least they aren’t wasting their evenings and weekends at the library feeding mountains of quarters into overheated Xerox machines in order to photocopy journal articles...)
The progress in MS research is a fantastic phenomenon that has already revolutionized the treatment of this complex disorder. The number of participants and abstracts at international meetings like ECTRIMS has grown dramatically, increasing the challenges of staying abreast of important developments. Few, if any, attendees will have the fortitude to view every poster and attend all the lectures. This places a heavy responsibility on those who write summaries, perspective articles and commentaries to ensure that their reports are accurate, balanced, concise, and well written. Even more importantly, these encapsulations must be interesting, or few will invest their spare and fleeting moments to read them!
Bates, D. 10 years of progress. Report from selected presentations at the 19th ECTRIMS Congress, 17-20 September 2003, Milan, Italy. The International MS Journal 2003;10:121.
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