THE UNDERLYING ISSUES

RELAPSES ARE ONLY A PART OF THE BIGGER PICTURE

There is no single way to identify MS progression. As you may see in your practice, there's a high degree of heterogeneity among RRMS patients, and every patient can present with a unique variety of symptoms that can lead to progression.1,2

In a clinical study, patients who were older at onset, and who experienced more frequent relapses earlier on, were more likely to progress to SPMS sooner.1

Relapse events can mask the recognition of progressing MS, while disability accumulates in the background. Although patients may remain in a transitional period for a longer amount of time, they may be less likely to recognize some of the impactful signs of their MS progression.3,4

The Underlying Issues, Banner The Underlying Issues, Banner

READ BETWEEN THE RELAPSES

Patients in the early stages of RRMS often recover to a new, lower functioning baseline following a relapse.5

A lower frequency of relapses after a few years with RRMS may indicate that an untreated patient's MS is moving toward a secondary progressive phase. This can often be misinterpreted as a respite from relapse.6

VISUALIZING THE TRANSITION TO SPMS7

Disability Can Worsen as the Frequency of Relapses Decreases, Graph Disability Can Worsen as the Frequency of Relapses Decreases, Graph

Over time, the frequency of relapses diminishes, but disability may continue to worsen.7

  • Progression of disability is believed to occur when the central nervous system can no longer recover from ongoing irreversible tissue damage7

  • A complex interplay of demyelination, axonal loss, and gliosis all contribute to progression8

Fewer relapses and diminishing MRI activity may indicate a transition to SPMS.7

  • Fewer active lesions on an MRI can mean less inflammation but potentially more progression9,10

  • Patients can sustain relapses concurrently with the progression of their disease11

Neurodegenerative factors eventually become the key elements responsible for disease progression, independent of inflammatory responses.9 These factors can include

Neurodegenerative factors eventually become the key elements responsible for disease progression, independent of inflammatory responses.9 These factors can include

  • White matter lesion type

  • Gray matter (cortical) involvement

  • Remyelination failure

  • Axonal/neuronal loss

  • Trapped inflammation

  • Specific mechanisms (oxidative stress, damage to iron species, mitochondria dysfunction)

IT'S CRITICAL TO CONSIDER THE TOTALITY OF YOUR PATIENTS' DISEASE STATE TO DETERMINE IF THEY HAVE PROGRESSED BEYOND RRMS.

IT'S CRITICAL TO CONSIDER THE TOTALITY OF YOUR PATIENTS' DISEASE STATE TO DETERMINE IF THEY HAVE PROGRESSED BEYOND RRMS.

SEE HOW PROGRESSION CAN PRESENT

TRACK THE TRANSITION arrow

MRI=magnetic resonance imaging; MS=multiple sclerosis; RRMS=relapsing-remitting MS; SPMS=secondary progressive MS.

References: 1. Scalfari A, Neuhaus A, Daumer M, Muraro PA, Ebers GC. Onset of secondary progressive phase and long-term evolution of multiple sclerosis. J Neurol Neurosurg Psychiatry. 2014;85(1):67-75. 2. Secondary progressive MS. National Multiple Sclerosis Society website. https://www.nationalmssociety.org/What-is-MS/Types-of-MS/Secondary-progressive-MS. Accessed July 10, 2018. 3. Tremlett H, Zhao Y, Devonshire V. Natural history of secondary-progressive multiple sclerosis. Mult Scler. 2008;14(3):314-324. 4. Katz Sand I, Krieger S, Farrell C, Miller AE. Diagnostic uncertainty during the transition to secondary progressive multiple sclerosis. Mult Scler. 2014;20(12):1654-1657. 5. Ontaneda D, Rae-Grant AD. Management of acute exacerbations in multiple sclerosis. Ann Indian Acad Neurol. 2009;12(4):264-272. 6. Scalfari A, Neuhaus A, Degenhardt A, et al. The natural history of multiple sclerosis, a geographically based study 10: relapses and long-term disability. Brain. 2010;133(Pt 7):1914-1929. 7. Fox RJ, Cohen JA. Multiple sclerosis: the importance of early recognition and treatment. Cleve Clin J Med. 2001;68(2):157-171. 8. Confavreux C, Vukusic S, Moreau T, Adeleine P. Relapses and progression of disability in multiple sclerosis. N Engl J Med. 2000;343(20):1430-1438. 9. Ontaneda D, Thompson AJ, Fox RJ, Cohen JA. Progressive multiple sclerosis: prospects for disease therapy, repair, and restoration of function. Lancet. 2017;389(10076):1357-1366. 10. Diagnosing SPMS. National Multiple Sclerosis Society website. https://www.nationalmssociety.org/What-is-MS/Types-of-MS/Secondary-progressive-MS/Diagnosing-Secondary-Progressive-MS. Accessed July 10, 2018. 11. Gross HJ, Watson C. Characteristics, burden of illness, and physical functioning of patients with relapsing-remitting and secondary progressive multiple sclerosis: a cross-sectional US survey. Neuropsychiatr Dis Treat. 2017;13:1349-1357.