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Multiple Sclerosis Multiple Sclerosis Management – A Changing Landscape 2013 Proceedings of the Meeting: Multiple Sclerosis Management – A Changing Landscape 2013, held on 26–27 April 2013 in Vienna, Austria Reviewed by Per Soelberg Sørensen, 1 Massimo Filippi 2 and Wolfgang Brück 3 1. Director, Danish Multiple Sclerosis Center and Professor of Clinical Neurology, University of Copenhagen, Denmark; 2. Associate Professor of Neurology, Vita-Salute San Raffaele University, Milan, Italy; 3. Professor of Neuropathology, Göttingen University Medical School, Göttingen, Germany Abstract The aims of this educational meeting, held in Vienna, Austria, were to explore the significant advances that have occurred in multiple sclerosis (MS) management over the past two decades, to highlight modern-day perspectives and challenges and to consider the impact of the new oral first-line treatments expected to enter the MS market shortly. The meeting was attended by 372 delegates with neurological interests from 30 countries and was opened by Per Soelberg Sørensen (Copenhagen, Denmark). Keywords Multiple sclerosis, magnetic resonance imaging, pathophysiology, role of injectable agents, oral agents, individualised therapy Disclosure: Multiple Sclerosis Management: A Changing Landscape 2013 was an independent educational meeting funded by an educational grant from Teva Pharmaceuticals Inc. Acknowledgements: Editorial assistance was provided by James Gilbart at Touch Medical Media. The following expert presenters also reviewed the content of these proceedings prior to publication: Julián Benito-Léon (Madrid, Spain), Angie Fagerlin (Ann Arbor, Michigan, US), Franz Fazekas (Graz, Austria), Oscar Fernandez (Málaga, Spain), Gavin Giovannoni (London, UK), Maria Houtchens (Boston, Massachusetts, US), Raj Kapoor (London, UK), Michael Khalil (Graz, Austria), Bernd Kieseier (Düsseldorf, Germany), Hans Lassmann (Vienna, Austria), Fred D Lublin (New York, New York, US), Gianluigi Mancardi (Genoa, Italy), Lauren Strober (West Orange, New Jersey, US), Marc Tardieu (Paris, France), Alan Thompson (London, UK) and Mauro Zaffaroni (Gallarate, Italy). Received: 1 November 2013 Accepted: 11 November 2013 Citation: European Neurological Review, 2013;8(2):105–114 Correspondence: Per Soelberg Sørensen, Danish Multiple Sclerosis Center, Department of Neurology 2082, Rigshospitalet, DK-2100 Copenhagen, Denmark. E: pss@rh.dk Support: The publication of this article was supported by Teva Pharmaceuticals Inc. The views and opinions expressed are those of the expert presenters and not necessarily those of Teva Pharmaceuticals Inc. Multiple Sclerosis Management 2013 The keynote lecture was given by Fred D Lublin (New York, New York, US), who outlined present and future challenges in the treatment of multiple sclerosis (MS). His theme was: where are we with current MS treatments and at what stage should patients be treated? There are now 10 marketed disease-modifying agents with seven different modes of action (all anti-inflammatory) for MS treatment and more have been submitted for regulatory approval. 1–4 Most of these treatments focus on clinically isolated syndrome (CIS) and relapsing remitting MS (RRMS). 5 The biggest challenge in MS treatment is progressive disease: the majority of current treatments are approved for RRMS and are much less effective in progressive disease. 6 Consequently, many patients with secondary progressive MS (SPMS) feel abandoned. The most valid treatment strategy currently is to treat early and delay or prevent SPMS. 7 There is considerable research effort in progress to address the progressive stage of the disease, but repairing damaged or lost axons is challenging. Therefore, despite the ongoing emergence of new agents, there remain many unmet treatment needs in MS therapy. 8 An important question in MS is which patients should be treated and when? Some studies have suggested that certain immunophenotypes and © TO U CH MED ICA L MEDIA 201 3 pathophenotypes predispose MS. 9,10 The change in the Macdonald criteria, including dissemination of MRI lesions in time and space, has increased diagnostic sensitivity and specificity 11 and this has helped determine which patients are at risk and need to start treatment to inhibit or prevent accumulating neurological damage. In clinical terms, MS progresses in steps of incomplete recovery leading to gradual worsening. In pathological terms, neuronal inflammatory disease leads to degeneration. This progression is driven by exacerbations 12 and reducing their incidence through disease-modifying treatment (DMT) has advantageous long-term consequences. To better reduce relapses and inhibit progression, some investigators have tried concomitant use of first-line DMTs in MS. The CombiRX study was an example of this approach. Sponsored by the US National Institutes of Health (NIH), the CombiRx study, a phase III, three-year-long study included 1,008 patients with RRMS and combined both glatiramer acetate (GA) treatment and interferon beta-1a (IFNb-1a) compared with these agents given separately. 13,14 In all of the three different definitions of exacerbations used in the CombiRx trial, GA monotherapy showed a significantly greater reduction on relapse rate compared with IFNb-1a treatment. In the efficacy head-to-head trial arm, GA monotherapy was superior to IFNb-1a in reducing the risk of exacerbation. The combination did show advantages 105