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THE PRESENT AND FUTURE OF
MS
Scott Belliston, DO
Multiple Sclerosis Clinical Fellow
DISCLOSURES
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None
NEW ERA
2010 Gilenya (Fingolimod) is approved by the
FDA as the first oral therapy for RRMS
 2012 Aubagio (Teriflunomide) is approved by the
FDA
 2013 Tecfidera (Dimethyl Fumarate) is approved
by the FDA
 2015 Lemtrada (Alemtuzumab) is approved by
the FDA
 2015 Glatopa (Glatiramer Acetate) the first
generic approved by the FDA
 2016 Zinbryta (Daclizumab) is approved by the
FDA
 14 DMDs for the treatment of RRMS
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PRESENT
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Risk
Diagnosis
Treatment
Symptom management
RISK OF MS
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Many theories have been proposed
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CCSVI
Environmental
Viruses
Genetic factors
Vitamin D deficiency
Melatonin
Smoking
Obesity
Hormones
Gut microbiota
DIAGNOSTIC TOOLS
MRI
 Lumbar puncture
 Evoked potentials
 Optical Coherence Tomography
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DACLIZUMAB
14th FDA approved medication for relapsing
remitting MS
 Unique monoclonal antibody against IL-2
receptors
 3rd line agent due to risk of hepatotoxicity,
autoimmune hepatitis and other immune
mediated disorders
 Requires REMS certification for both physician
and patient
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REMS
Risk Evaluation and Mitigation Strategy
 FDA can require a drug to have a REMS program
 Manufacturers required to follow guidelines to
ensure that the benefits of a medication outweigh
it’s risks.
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OCRELIZUMAB
Monoclonal antibody that targets B cells
 May be the first of many drugs for progressive
MS
 Granted Breakthrough Therapy by FDA
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Clinical trials for progressive MS
 High dose biotin
 Tcelna for secondary progressive
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LAQUINIMOD
Oral medication
 Reduces leukocyte migration to the CNS
 Trials ongoing for RRMS, PPMS, and SPMS
 Higher dose trial suspended due to
cardiovascular events
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IBUDILAST
Oral medication
 Used as an anti-inflammatory drug in Japan for
treating neuropathic pain
 Appears to have neuroprotection
 Ongoing trials for SPMS and PPMS
 Was granted a fast track by the FDA
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SIPONIMOD
Oral medication
 Selective sphingosine-1-phoshate receptor
modulator
 Just announced positive outcome in phase III
trial for reduction in disability progression
compared to placebo
 Further results to come at ECTRIMS
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ANTI LINGO AND REMYELINATION
Unfortunately Anti Lingo failed outcome
measures in phase 2 studies
 This is one of many drugs to come with goal of
remyelination
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MORE AGGRESSIVE TREATMENTS
We are getting better at treating RRMS
 We are seeing more adverse events
 More immunosuppression with subsequent
infections including PML
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SYMPTOM MANAGEMENT
Ampyra (dalfampridine) “the walking drug”
approved in 2010
 First medication to get FDA approval specifically
for symptom management in MS
 It works by helping nerve transmission across
demyelinated nerves
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SYMPTOM MANAGEMENT
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Incontinence
Botox
 Vesiflo
 Video
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THE FUTURE
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What does the future of MS look
like
Causes of MS
Cure of MS
Prevention of MS
MEDICINE IS RAPIDLY CHANGING
TECHNOLOGY IS PUSHING US FORWARD
Video
Video
Wheelchair Video
Wheelchair Video
2
WHAT CAUSES MS?
More risk factors to be found
 Better understanding of the dysfunctional
immune system
 More gene testing and understanding the
genetics of MS
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INCIDENCE
Increasing overall not just improved diagnosis
 Charcot thought that it was more common in
men
 In the early 1900s it was thought to be equal in
men and women
 In the 1970’s it was 2:1 women:men
 Now it is close to 3:1
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DIAGNOSIS IN THE FUTURE
Average time to diagnosis quicker
 Blood tests to confirm diagnosis
 Use of MR spectroscopy, Functional MRI, or PET
scans
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BIOMARKERS
As we now have 14 DMDs and all have
potentially significant side effects and some work
better in one person than another.
 Biomarkers including blood, CSF, or genetic
markers that will help guide us in choosing the
right DMD for a patient.
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CLEMASTINE
Anti histamine showing evidence of stimulating
myelin repair of the optic nerves
 Why Clemastine????
 Jonah Chan PhD
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Video
STEM CELL THERAPIES
The NMSS is currently supporting 12 trials for
stems cells in MS
 They have supported 68 trials over the last 10
years
 Currently no treatment with stem cells therapy
has been approved
 Mesenchymal stem cells
 Autologous stem cell transplantation
 Improvement in safety and efficacy
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HALT-MS
High-Dose Immunosuppressive Therapy and
Autologous Hematopoietic Cell Transplantation
for Relapsing-Remitting Multiple Sclerosis
 25 patients were enrolled
 24 received the treatment
 5 year trial
 1 patient died
 70% remained free of disease activity at 3 years
with no relapses, no new MRI detected lesions,
and no signs of progression
 40% experienced a reduction in their disability
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TREATMENTS
We need treatments with less risk and more
benefit
 More affordable medications
 Generic medications
 Vaccination for JC virus, prevent possibility of
PML
 Medications for progressive MS
 Medications for remyelination
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SYMPTOM MANAGEMENT
Better medications for symptoms
 Medications specifically for fatigue
 Walking
 Pain
 Incontinence
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Bardia Nourbakhsh,
MD
A CURE
This is a real possibility
 What is a cure
 More than stopping progression
 We aren’t there yet
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PREVENTION
Ability to predict who is at risk of MS
 Vitamin D supplementation
 Melatonin
 Vaccination?
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ACKNOWLEDGEMENTS
QUESTIONS