An important study from the Weill-Cornell Medical College in New York has examined the outcomes of the relatively small group of people with MS who have a rapid, aggressive course right from the time of diagnosis.

An important study from the Weill-Cornell Medical College in New York has examined the outcomes of the relatively small group of people with MS who have a rapid, aggressive course right from the time of diagnosis.

This group has been poorly defined in the past, but may represent up to 9% of people with MS. Using their own database of 1000 PwMS enrolled since 2008, they defined aggressive onset MS (AOMS) as PwMS who had 2 or more relapses in the first year and 2 or more active lesions on MRI, but also accepted those people who had only one relapse if that relapse caused sustained serious fall in the disability score (EDSS) and they had 2 or more active lesions.

The use of conventional medicine

Defining AOMS this way they found that 7.4% of their group had such aggressive disease. Examining the subset of these for whom there was complete data, they had a median age of 33, were mostly (70%) women, and 81% were started on first-line injectables like glatiramer or the interferons.

This probably reflected that there were many people in the sample diagnosed before the widespread use of second-line, more potent drugs like fingolimod and natalizumab. In short, they showed that the disease continued to be very active much more commonly in the group with the first-line drugs than those with the more potent drugs.

About two-thirds of those started on these first-line drugs had to be switched to the more potent drugs because the disease was still active, on average at around 9 months. Pretty much all the patients (28 of 30) who were switched to more potent treatment or received it right from the start achieved control of the disease, with no evidence of disease activity.

Early detection of MS

The authors argued the importance of identifying people with MS with aggressive disease early and getting them onto the more potent medications as quickly as possible. Prof Gavin Giovannoni, in his popular Barts MS Blog agreed, noting that we have methods of detecting aggressive disease early using neurofilament analysis of cerebrospinal fluid (measuring certain proteins in fluid around the brain via lumbar puncture).

This is clearly an important issue; we need reliable methods of detecting those people with MS at diagnosis who will deteriorate quickly, so that we can offer them potent therapies, not only second-line immunomodulators, but potentially some of the more aggressive therapies now being trialled, such as stem cell transplantation.

The critical role of lifestyle in MS

Of course, it is important that the long term outcomes are not forgotten, and that these people are also made aware of the critical importance of attending to lifestyle issues that will be familiar to OMS readers.

It makes no sense getting early control of the illness with potent medication and not doing anything about long term stability through secondary prevention with diet, exercise, smoking cessation, and so on. 

George Jelinek