Clinical Decision-Making in Multiple Sclerosis CME/CE
Kathleen Costello, MS, ANP-BC, MSCN, Chair; Ralph H. Benedict, PhD; George H. Kraft, MD, MS; Michael K. Racke, MD
CME/CE Released: 08/24/2009; Valid for credit through 08/24/2010

http://cme.medscape.com/viewarticle/705561

Target Audience
This activity was developed for neurologists, nurses, and physician assistants who specialize in the care of patients with MS.

Goal
There are currently 6 agents approved by the FDA for the treatment of MS, including 3 forms of interferon beta (IFN β): glatiramer acetate (GA), natalizumab, and mitoxantrone. IFN β and GA are considered immunomodulators that reduce the frequency of relapses in patients with relapsing remitting MS (RRMS), while natalizumab and mitoxantrone are considered second-line therapies for patients who are not responsive to immunomodulators. Although none of these agents are considered curative, this approach will continue to be the basis of treatment in the near term. The National Multiple Sclerosis Society has cited underutilization of disease-modifying therapies (DMTs) as a barrier to treatment, and an estimated 38% of potential candidates for treatment with a DMT are not continuously treated with one. The purpose of this educational activity is to increase clinician competence in the management of patients who have had their first demyelinating event (clinically isolated syndrome [CIS]) and those who have been diagnosed with MS.

Authors and Disclosures
Kathleen Costello, MS, ANP-BC, MSCN
Faculty Associate, University of Maryland, School of Nursing, Multiple Sclerosis Program Director, ALS Clinic Coordinator, University of Maryland, Department of Neurology, Baltimore, Maryland
Disclosure: Sources of Funding for Research: None; Consulting Agreements: Biogen Idec, EMD Serono Inc; Speakers' Bureau/Honorarium Agreements: Bayer HealthCare Pharmaceuticals, Biogen Idec, EMD Serono Inc, Teva Neuroscience Inc; Financial Interests/Stock Ownership: None; Discussion of Off-Label, Investigational, or Experimental Drug Use: None.

Ralph H. Benedict, PhD
Professor, Department of Neurology, SUNY Buffalo, Staff Neuropsychologist, Buffalo General Hospital, Buffalo, New York
Disclosure: Sources of Funding for Research: Biogen Idec, Cognition Pharmaceuticals Inc, Shire; Consulting Agreements: Cognition Therapeutics Inc, EMD Serono Inc, Pfizer Inc, Shire; Speakers' Bureau/Honorarium Agreements: Bayer HealthCare Pharmaceuticals, Biogen Idec; Financial Interests/Stock Ownership: None; Discussion of Off-Label, Investigational, or Experimental Drug Use: None.

George H. Kraft, MD, MS
Alvord Professor of MS Research, Departments of Rehabilitation Medicine and Neurology, Principal Investigator, Multiple Sclerosis Rehabilitation Research and Training Center, University of Washington, Director, Western MS Center, University of Washington Medical Center, Seattle, Washington
Disclosure: Sources of Funding for Research: National Institute of Disability and Rehabilitation Research, National Institutes of Health, National MS Society; Consulting Agreements: Bayer HealthCare Pharmaceuticals, Biogen Idec, EMD Serono Inc; Speakers' Bureau/Honorarium Agreements: EMD Serono Inc; Financial Interests/Stock Ownership: None; Discussion of Off-Label, Investigational, or Experimental Drug Use: Nonapproved doses of IFN ?-1b and glatiramer acetate are investigational.

Michael K. Racke, MD
Chairman, Department of Neurology, Ohio State University College of Medicine, The Ohio State University Medical Center, Columbus, Ohio
Disclosure: Sources of Funding for Research: National Institutes of Health, National Multiple Sclerosis Society; Consulting Agreements: Peptimmune, Teva Neuroscience Inc; Speakers' Bureau/Honorarium Agreements: Bayer HealthCare Pharmaceuticals, EMD Serono Inc; Financial Interests/Stock Ownership: None; Discussion of Off-Label, Investigational, or Experimental Drug Use: Anti-infectious agents, azathioprine, cladribine, cyclophosphamide, intravenous immunoglobulin, matrix metalloproteinase inhibitors, methotrexate, mycophenolate mofetil, statins; combination treatments, and pulse corticosteroids are investigational.

Rosalee Blumer
Disclosure: Rosalee Blumer has nothing to disclose.

Chris Fischer
Disclosure: Sources of Funding for Research: None; Consulting Agreements: None; Speakers' Bureau/Honorarium Agreements: None; Financial Interests/Stock Ownership: Johnson & Johnson Services Inc, ZymoGenetics Inc.

Learning Objectives
Upon completion of this activity, participants should be able to:

1. 1. Identify a patient who is likely to develop MS after a CIS by applying diagnostic criteria and recognizing high-risk patient characteristics.
2. 2. Identify the most appropriate DMT for a patient who has had a CIS, using clinical trial data and consensus guidelines.
3. 3. Determine the most appropriate DMT for a patient who has RRMS and is stable on, not responding to, or not tolerating current treatment, using clinical trial data and consensus guidelines.
4. 4. Recognize the importance of clinician–patient communication, emphasizing the risks and benefits of early treatment, the need for proactive management of possible adverse effects, treatment limitations, and possible long-term effects on disability and cognition.