Happy New Year. We hope you all had a good festive break. The following are some of what we at Barts-MS want to achieve and work towards in the next decade.
We have little doubt that MS is a preventable disease and by tackling many of the environmental risk factors we may be able to turn around the MS epidemic and see a fall, or at least a levelling off, in the incidence of MS. This does not mean the prevalence of the disease, i.e. the number of people with MS, will fall. As we get better at managing MS more pwMS will be living longer and healthier lives. We need the whole MS community to get behind #PreventMS
The MS community will accept that MS is foremost a preventable dementia. MS-related cognitive impairment will become a major treatment target, both symptomatically and for disease modification. Physical impairment won’t go away, but it will become less of an issue with the wide adoption of early effective treatment to prevent disability. We will shift our treatment targets away from focal inflammation and relapses to target the #RealMS, i.e. smouldering disease. Smouldering MS will become the new frontier and we want to be one of the pioneering groups working in this area.
We now realise that monotherapy will only get us so far in terms of reducing the burden of MS. We will need to explore combination therapy strategies and learn from our colleagues in other disease areas. Hopefully, the regulators will understand the need to move to a combination treatment paradigm and create the necessary regulatory framework for this to happen in.
It is clear that the philosophy of marginal gains will need to be adopted to maximise the brain health for the lifetime of people living with MS. DMTs are clearly not enough. This will mean reconfiguring MS services to tackle comorbidities and to help pwMS adopt the necessary lifestyle changes to make small, but important, differences to their outcomes.
This is a new theme for the decade. We are our metabolism and MS is first and foremost a metabolic disease. Can we hack our metabolism in a way that will improve MS outcomes? I am sure we can and this will be done using diet, supplements, exercise and medications to alter our microbiomes and stimulate our metabolism to work with us with the aim of maximising brain health. There is good evidence that caloric restriction, intermittent fasting and ketogenic diets do this already. Can we make this more scientific? Can we add medication to the mix to make sure we are getting it right?
The next decade will see massive transformation in the way we provide NHS services to pwMS. Gone will be the old Victorian model of healthcare and it will be replaced by a network model that is run by people with the disease and not the HCPs. The current healthcare model is broken and unsustainable.
The MS community will realise that the social determinants of health (SDoH) are as important to pwMS as they are for other disease areas. We will see service developments in the NHS to tackle SDoH and social isolation. We are not sure of what format these will take, but anyone who ignores the SDoH will not be able to maximise their outcomes.
We will see the completion of the #ORATORIO-HAND and #CHARIOT-MS trials and the recognition that MS is modifiable throughout its disease course. We anticipate a whole raft of other trials starting that will target upper-limb and hand function as their primary outcome. We anticipate DMTs being started and continued in advanced MS (EDSS>=7.0).
We anticipated that the McDonald diagnostic criteria being challenged by technology, in particular, biomarkers, and having to rapidly adapt to a changing landscape. Asymptomatic MS will be a new diagnostic category. We will be providing screening to high-risk individuals and diagnosing and treating MS in the asymptomatic stages.
The MS community, including the regulators, will realise that MS is a biological disease and that salami-slicing up MS into pseudo-disease categories is doing pwMS a disservice.
The wider MS community will adopt HSCT as a very high efficacy DMT for treating MS. HSCT will become just another DMT on the list of potential treatment options. Many of the head-2-head studies comparing HSCT to licensed high-efficacy licensed DMTs will show that HSCT is at least as effective, and probably more effective, than our licensed DMTs but will come with higher risks. The wide adoption of HSCT as an MS treatment option will mean that pwMS won’t have to travel abroad for treatment.
The international community will get behind the Grass-Roots Affordable DMT (GRAD) Initiative to make sure people living with MS in resource-poor environments get access to MS services and affordable treatments. This has to happen as soon as possible; we can’t expect pwMS living without treatments to have to wait a decade.