Clinical Implications of Latest Therapuetic Data for Congition in MS

Stefan Krieger, MD: Now that we’re starting to get a sense that drugs like S1P modulators and ozanimod (Zeposia; Novartis) can improve cognitive function, or certainly prevent its deterioration, better than our older drugs, it was interesting to look at other modern disease-modifying drugs Therapies through the same lens. At that meeting, data from the ofatumumab study (Kesimpta; Novartis) and the ASCLEPIOS study (NCT02792218), which evaluated ofatumumab versus oral teriflunomide (Aubagio; Sanofi), also showed a similar cognitive profile. More patients in the ofatumumab treatment arm achieved improvement in cognitive function than those randomized to receive teriflunomide. And again, it was consistently observed that a greater percentage of patients improved than worsened. It speaks to the strength of higher efficacy therapies against both an older oral and, of course, older injectable platform like interferon in the ozanimod trials. I think it paints a somewhat optimistic picture of what we can hope for from modern MS therapies in the cognitive arena.

One outcome I think for the field from the idea that disease-modifying therapy can potentially stabilize or even improve cognitive function in MS is that we really need to look for it. You could understand it in the olden days when you felt like there was nothing you could do about it – which probably wasn’t even then – but now there really is potentially something we can do about it, not just through brain health interventions, but through illness. modify therapy. It’s really up to us to take it seriously, look to quantify cognitive function, and use that as a result for what we want our disease-modifying therapies to do. I also think it can be a useful motivator for our patients. As a clinician, how many times have I encouraged people to change their diet and exercise and go to physical therapy or occupational therapy? I think if we wrap this in the notion of improving brain health, have both disease-modifying therapy and these reserve-building techniques, I think this can be inspiring to people. In turn, it may give them a reason to return to the idea that cognitive functioning and cognitive abilities are very closely related to identity—people care. And I think that means we should take care of it and we should be careful when we look for it and try to improve it.

I think the big benefit for me has been the cognition assessment, ideally early on when someone is diagnosed with MS or comes into my office to get a snapshot of where we’re starting. That’s our benchmark, it’s our benchmark for where they are and where we’re going to try to push them to improve from there. I also think that it almost doesn’t matter what cognitive test someone uses, whatever they can incorporate into their practice. If it’s as short as the SDMT, great, you’re getting the hang of it – it’s a good starting point. Having a lot of findings on the SDMT could lead you to refer a patient to a more formal neuropsychological assessment or to one of the computerized batteries. For places that have neuropsychologists or a neuropsychology program, I think it’s pretty important to get them on board to get involved in the care of people with MS. And not to be nihilistic to think that there’s a lot we can do about it and that we need to have that data on hand if only we have better and better therapies that can help treat this symptom and improve ourselves for the to lead the future.

We all know how to take anamnesis with our patients and learn about them. But my favorite question—that would be my advice to someone thinking about how I might incorporate cognitive function assessment into their MS practice—is for someone who is employed, “Did you have your performance review this year?” Did you have yours Performance evaluation? It opens a small window into someone’s life in their abilities or outside of the office visit. I may not only see signs of cognitive dysfunction at routine visits. But if I find out through this question that the person is struggling at work, not meeting their deadlines, not being able to multitask efficiently, making mistakes, forgetting things, being reprimanded… that tells me something about what is happening that I might not have been able to see in my clinical examination. It gives me reason to go further and take a closer look at their cognitive function. On the other hand, when someone tells me they’ve been promoted, they’ve been given more responsibility, things are going really well – that’s great. That gives me a sense of where they are now and even more a mandate to try to keep them at that high level.