Risk of relapse from delayed initiation of treatment

Gavin-Giovannoni-150x150Professor Gavin Giovannoni
Department of Neurology
Royal London Hospital

Earlier this week I mentioned that I was appalled by the observation that where you live in the country and how your local MS service is configured determines how quickly you can access DMTs.

In one English town all patients had to be referred to a regional neuroscience centre taking on average 9 months to get onto a DMT, whereas in another similar-sized town with a local MS service patients managed to get onto treatment within 8 weeks. Does this make a difference? In this US electronic health record study patients who initiated DMTs later, i.e. > 3 months after being diagnosed with MS, were more likely to have a relapse than patients starting DMT within 3 months. Time matters!

Some people may say that as MS is a lifetime disease a short delay is neither here nor there in the grand scheme of things. I disagree. For every relapse their is ~10 white matter MRI lesions that occur asymptomatically. For every visible white matter lesion there is over 25 microscopic white matter lesions that the pathologists will see under the microscope. As we now know MS is as much a gray matter disease as a white matter disease how much activity are we missing in the gray matter. Therefore one relapse indicates that a lot more damage is occurring that meets the eye. This is why I continually push the issue of Time Matters in MS. It is also important to realise that once damage occurs in MS it is generally irreversible and that if recovery occurs it is due to plasticity and other compensatory mechanisms. Once we exhaust these recovery mechanisms worsening MS become clinically apparent (formerly known as progressive MS).

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