#ClinicSpeak: Is progressive MS modifiable?

Please hand me my rose-tinted glasses; I need to lend them to my colleagues. #ClinicSpeak #MSBlog #ECF2016

I had a bit of a disagreement with several of my colleagues in Baveno. 

One didn't like the conclusion I drew about therapeutic lag and the effect of highly-active DMTs in so called 'non-relapsing progressive MS'. He was of the opinion that if we allowed people with progressive MS, who had no evidence of inflammatory activity on their MRIs, to be treated we would bankrupt the healthcare system. I pointed out to him that the majority of subjects in the natalizumab-SPMS, or ASCEND, trial had no MRI activity and they still responded to natalizumab. Similarly, both the MRI-active and MRI-inactive groups in the ocrelizumab in PPMS, or ORATORIO, trial responded to drug. What this is telling is that MRI is not the be-all and end-all of inflammatory monitoring. It is clear that there must still be inflammation going on beyond the detection threshold of the MRI; in fact, we have known this from pathology studies done more than 20 years ago. 

Another argument I had with him is that if we worry about costs and not the unmet need (progressive MS and loss of upper limb function) then we would be paralysed forever (excuse the pun). Pharmaceutical innovation costs are front loaded; in time the prices of drugs drop precipitously and become relatively cheap. When I was a house officer, and a medical registrar, there was a big debate about the high cost of statins and H2-receptor blockers; how could we as a society afford them? Fast forward 30 years and these drugs costs a few pence per day. The same will happen with DMTs in MS;  trust me when I say that sometime in the future the cost of MS DMTs will be a fraction of what they cost today. Another factor to take into account is value-based pricing. In other words healthcare systems will work out how much to pay for DMTs in the more advanced stages of MS and they will negotiate a hard bargain with Pharma to reduce the costs. NICE does this already; what they do well is value-based pricing. 

Another argument I had was about my MS is 1-disease-not-2-or-3-diseases campaign. Several people disagreed. In the voting poll 48%, just shy of a majority, agreed with me. If I can get the community to accept this proposal then there should not be any resistance to treating MS as one disease. To get to this position you have to accept that MS is a modifiable disease even in the more advanced stages. 

I know what you are saying to yourself; 'Prof G must have written this post wearing his new rose-tinted spectacles'. 


CoI: multiple

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