Well, it’s been a busy year, but I have saved up some topics for the blog. ECTRIMS 2013 was a plethora of presentations, many of which were not unexpected, and a few that were a surprise. Lifestyle issues in MS continue to increase in importance for the health and management of the severity of MS.  ITS THE SALT STUPID Most surprising is the first clinical paper supporting earlier animal studies in EAE (and suspicions in related autoimmune diseases), namely that  sodium intake is a key regulator of the aggressiveness of the inflammatory response in MS. Mauricio Farez, MD, from the Institute for Neurological Research, Buenos Aires, Argentina presented an MRI and clinical study of individuals with results stratified to dietary sodium intake.     Exacerbation rate was threefold higher with moderate and fourfold higher with high sodium intake relative to a low sodium diet. Individuals with high sodium intake had on average 8 more lesions and more than threefold risk of new lesions on MRI. Sodium intake is an astonishingly important and heretofore unappreciated environmental risk factor for the severity of MS, and a very attractive approach in the adjunctive therapy of the disease. It may also explain the increasing prevalence of MS in populations with a Western diet. Even if repeat studies show a much smaller effect, the insights which such a mechanism offer into control of the disease have implications for every physician who sees multiple sclerosis. Other lifestyle issues continue to be reviewed. Vitamin D3 deficiency is now recognized as a fundamental cause and exacerbating factor of MS. Tobacco use has been seen also to be an important factor in the cause and severity of MS. GELINYA IS REALLY GOOD Many presentations on existing therapies and investigational agents nearing approval continue to support the  previously recognized efficacy of these MS immunotherapies. Gelinya (fingolimod) long-term studies support a robust, long-term, treatment effect on slowing and preventing brain atrophy, as well as enduring suppression of relapse rate and protection against   disability in a 5 year follow study from the original TRANSFORMS and FREEDOMS cohorts. Important data regarding the transition of patients from Tysabri (natalizumab) to Gelinya (fingolimod) was presented by several groups, making this transition a straightforward and palatable option for the management of PML risk for the majority of MS patients. LEMTRADA IS EVEN BETTER CAMPATH (the old name) or likely to be called Lemtrada (alemtuzumab), which is recently approved in Europe, and likely to have approval imminently in the USA, represents the most potent and effective therapy yet seen for multiple sclerosis, has robust effects at three years, with an expectation of improvement (not simply slowed progression) with 45% improved and 25% stable in disability at 3 years. The effect clearly continues beyond the treatment cycle years into the year where fewer patients receive a cycle. A new endpoint, 12 month sustained reduction in disability, was introduced which 27% of the subjects met.


by SAMUEL F. HUNTER, M.D., PH.D. on NOVEMBER 7, 2013