Clinical Features and Treatment Outcomes in MS An Update from Contemporary Cohorts PVA Summit –August 2013 Orlando, FL Mitchell T. Wallin, MD, MPH Clinical Associate Director VA MS Center of Excellence East-Baltimore Associate Professor of Neurology Georgetown University School of Medicine University of Maryland School of Medicine
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Clinical Features and Treatment Outcomes in MS · Onset sx: optic neuritis, sensory Onset sxs: motor, cerebellar, sphincter RR disease onset Severe disability after first attack ...
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Clinical Features and Treatment
Outcomes in MS An Update from Contemporary Cohorts
PVA Summit –August 2013 Orlando, FL
Mitchell T. Wallin, MD, MPH Clinical Associate Director
VA MS Center of Excellence East-Baltimore
Associate Professor of Neurology
Georgetown University School of Medicine
University of Maryland School of Medicine
Disclosures
This continuing education activity is managed and accredited
by Professional Education Services Group in cooperation
with the Paralyzed Veterans of America. Neither PESG
nor PVA nor any accrediting organization supports or
endorses any product or service mentioned in this activity.
PESG Staff and the Program Planning Committee have no
financial interest to disclose.
Commercial Support was not received for this activity.
Disclosures (cont.)
M. Wallin, MD, MPH has the following disclosures:
Biogen-Idec, Inc. Investigator Initiated Grant Support
Learning Objectives:
Understand the clinical course of MS in recent
population-based cohort studies
Discuss optimal models to study MS therapy
outcomes in representative patient populations
Provide an overview of current MS disease
modifying therapy use and the associated clinical
impact in large patient populations
Topical Outline
MS morbidity overview Relapses
Progressive disability
Gulf War Era MS Cohort
Clinical & research tools for MS outcomes
MS Disease Morbidity Timeline (Lublin F, Neurol in Clin Pract, 2008)
Relapses
EDSS, PDDS
MSFC
Imaging outcomes
Study population issues
Representative
Adequate size
Disease status
Controls
Follow-up time
*In 224 placebo patients from the NMSS task force on clinical outcome assessment.
Relapses Can Result in
Residual Long-Term Disability Lublin FD, et al. Neurology. 2003;61:1528-1532
Net Change in EDSS Score from before a Relapse to after a Relapse*
GWEMSC - Morbidity Figure 1. Cumulative probability of reaching DSS 6 from birth in years by Age at Onset. Control variables were: gender,race, disease course at onset, type of symptom at onset, and DMT use (see Table 6 for results).
• Main page allows for filtered cohort selection based on individual search preferences
Expanded Diagnosis & DMT Medication
Filter Options
Clinician Dashboard Display
• Current meds pulled from the Corporate Data Warehouse – updated daily
MS Risk Assessment Through the Lifespan
MS Disease Course
fewer relapses with full recovery (RRMS)
shorter disease history
DMT
Vitamin-D supplements (UVB exposure) ??
frequent relapses without full recovery (SPMS)
primary progressive disease course
longer disease history
comorbidities
smoking ??
OUTCOMESClinical
QOL
Disability
ADLs
MSSymptoms
Survival
Infections - Decubiti - UTI - Pneumonia
DVT / PE
Pro
tecti
ve
Exacerb
ati
ng
Ris
k F
acto
rs
Environmental
EBV, HHV-6
other viruses &toxin(s)
smoking ??vaccines ??
Equitorial Latitude
Vitamin-D (diet)
UVB exposure
Prognosticators@ onset of MS
Female
younger age
sensory symptoms
relapsing MS
Male
older age
motor symptoms
progressive MS
family HX of MS
NOTE: Items displayed in BLUE are EFFECT MODIFIERS that can varry naturally (e.g., living at a southern latitude) or are modifiable (e.g., smoking, DMT use). A '??" is placed next to those items that have been suggested, but not conclusively demonstrated, to impact MS risk or outcomes.
Birth ~10 ~20 ~40 Death
+
-
Clinical Features and Treatment
Outcomes in MS Conclusions
Relapses rarely associated with significant sustained disability progression in population-based studies
MS disease morbidity progression is more benign in recent population-based cohorts
MS clinical phenotype and course are age dependent and relatively uniform
US DoD/VA MS population-based cohort studies offer opportunity to evaluate: Incident MS (service-connection)
Real time disability & DMT outcomes: MS Assmt Tool & Databases