Augusto Miravalle, MD, FAAN, Associate Professor of Neurology, Associate Chair of Education, Chief, Multiple Sclerosis Division, Department of Neurology at the University of Florida discusses multiple sclerosis and a new study shedding light on a possible connection between MS patient symptoms and changes in their brain.
Interview conducted by Ivanhoe Broadcast News in August 2017.
How long have you been treating MS patients?
Dr. Miravalle: I have been treating MS patients for over nine years. I trained in Boston and I completed a fellowship, then I moved to University of Colorado. I was part of the Rocky Mountain MS Center and I spent eight years there, we were the largest center in the region in Colorado. The last time I was there we were seeing 6,000 visits per year, patients with multiple sclerosis and soldiers. I moved to Florida this past February.
This study talked about how there’s problems with reading social cues with people with multiple sclerosis and claims it may be tied to brain changes, what do you think about this study?
Dr. Miravalle: The study highlights one of the many problems our patients suffer, which is the way the brain assists in our recognition of official cues and social interactions and also highlights how multiple sclerosis affects entire central nervous system. Traditionally we thought of MS as supremely this disorder that affects only certain parts of the brain, now we are able to recognize that actually MS patients suffer from a variety of symptoms that affect anywhere from cognitive function to social interactions, mood disorders, and directly affects their interactions both at work, their performance, as well as personal relationships and clinical disability.
The medicine and treatment you give these patients, does that help them work through those problems?
Dr. Miravalle: You can in a practical way group the medicines that we offer to our patients into two big categories. One being the medicines that are intended to help with symptoms or symptoms management, examples are if a patient has depression or anxiety, we try to help them with the medicines that are targeting those symptoms. The other category of medicines that we use are what we call assist modifying therapies, and as the name implies those medications are intended to modify or impact the cores of multiple sclerosis.
What treatment and research are you doing today, recently treatment has progressed?
Dr. Miravalle: You are correct, one of the advantages that we have now in treating multiple sclerosis is though we have 15 approved medications for the treatment of both, relapsing and recent, we have the first approval for the medication for progressive forms for multiple sclerosis. All of these tools not only allow us to have more options but most importantly start challenging the way we looked into the definition of treatment success or failure. In the past when we only had few options to choose from and those medications partially impact these progressions of multiple sclerosis, we simple had to limit our options to inject all therapies, and those even though effective they only partially suppress the evolution of the disease to an estimated 30 percent reaction in the overall base of progression. Now we have medications that range anywhere between 80 to 95 percent reaction in the risk of progression of disability and new lesions and relapses.
Where once people were told when they were diagnosed with multiple sclerosis they thought oh my gosh in seven years I am going to be in a wheelchair, I am not going to be able to move; now there is hope?
Dr. Miravalle: That is exactly correct. That is why it is very important to emphasize early diagnosis, early access to specialized centers in which they will not only make the correct diagnosis but also offer patients a personalized, customized, patient-centralized approach because every patient is different, but for the most part the expectations today are that with our therapies we expect pretty much nothing new, so no new lesions in the brain and no relapses or no clinical attacks where there is no evidence of this progression.
Do you find that that is a new research that in multiple sclerosis patients suffer when it comes to socials cues and this may be tied to brain changes, is that new?
Dr. Miravalle: It is a novel concept, it brings some importance of understanding that there are many unknown pathologies and problems that our patients suffer from and some of those are difficult to quantify. The basic concept is gaining some interest recently in the field of multiple sclerosis which is understanding the effects of brain resurface or neurological resurface, so what is that? Logical resurface is a functional part of the central nervous system that allows individuals to make those connections in the brain more efficiently and to also compensate loss of brain cells or pathology, in this case, multiple sclerosis; most compensate for stress and for normal aging, etc. One of the early impacts of multiple sclerosis has to do with exhaustion of that brain resurface as individuals have to compensate for the perorations and pathology of the brain. Some of these consequences which are difficult to quantify may be linked to the development of early pathology in the brain or neurology resurface.
Moving on past the study, what is the main research you are doing that you are very excited about?
Dr. Miravalle: What we are trying to understand is what are the downstream consequences of providing patients with high-effective therapies early on in the course of multiple sclerosis. For decades we have been looking at the traditional outcomes in multiple sclerosis being lesions, clinical relapses, as well as disability progression. However, those outcomes are pretty much the tip of the iceberg that is quite a lot of problems and disability that patients actually accumulate; they are not that easy to measure in the clinical setting. So we are trying to look into other outcomes including for example; swallowing difficulties, swallowing problems, sudden cognitive changes, one being perhaps stability for understanding facial cues in social interactions and memory, and trying to understand whether those outcomes also get impacted by the therapies that we are all offering to our patients.
Options of treatment have not changed yet, now we are seeing them improve?
Dr. Miravalle: Perhaps one of the biggest challenges is now we have options, we have understanding; who is the right candidate for the right therapy and when to use this therapy, how to sequence them because the benefits of the therapy are clearer, but also every medication brings different concerns in terms of safety and side effects. Sequencing of these medications may alter the side effects and safety for the next one, so the big challenge now is trying to understand with all these new options, who is the right patient for the right therapy and at what time.
What are the different ranges of challenges for people with MS?
Dr. Miravalle: One of the challenges of multiple sclerosis is that it affects pretty much individuals of all ages, even though the most difficult presentation is in females in their 30’s, MS affects males and females, even kids. We are actually building a pediatric MS center here at University of Florida. MS could also be in someone in their 60’s and their 70’s, so what that tells you is that it is a very heterogeneous disease and the amount of disability in every patient is different. That difference has to do with factors including the number of lesions in the brain or where lesions are located, but also going back to where we were talking before how much the brain is able to repair as well as compensate for pathology. This concept again the brain can reserve, and being able to rewire certain pathways in the brain when this pathology is able to compensate for that is a process from early on could affect the amount of disability.
Did you pick this specialty for a reason, why is it personal to you?
Dr. Miravalle: The reason has to do with helping the patients, when you assume a role as a provider for patients with multiple sclerosis you pretty much have the opportunity to walk with them through the entire process. And you work from early on in the process of the diagnosis to the later stages of the disease and that interaction is pretty fulfilling. It is something that I actually feel grateful and honored that I can be a part of that and in a sense it allows you to get to know these individuals more on a personal level. Sometimes we know family members and their pets even, so you truly establish a long lasting relationship.
Is multiple sclerosis heredity, or it just comes whenever?
Dr. Miravalle: You can call it that if you want, basically we do not know the cause of multiple sclerosis but we know it is multi-factoral. What that means is environmental factors play a role in increasing the risk of MS among those affected. Traditionally it had been thought to be perhaps a virus, among those the virus that causes mononucleosis has been linked with multiple sclerosis. Another factor in the environment that changes the risk is vitamin D in individuals who are deficient in vitamin D they have a higher risk of developing multiple sclerosis. When somebody has multiple sclerosis, being deficient in vitamin D they also can be linked to worse clinical outcomes. There is also geographic difference among different places in the world and that is actually being called latitude graded of MS where prevalence of the disease is actually higher, the farther away you get from the equator, and of course with migration and different patterns now where individuals move in the world that is changing and is getting mixed. For example, in Florida we have a large number of mixed patients but most of those patients are not native of Florida. These individuals acquired the disease elsewhere and then moved here later in life and this genetic component, which is 10 to 15 percent of patients with MS have a first degree with multiple sclerosis, there are now over 120 genes that has been described that changes the risk of somebody to develop MS. It is something that we are not born with but the combination of different factors actually changes the risk of somebody living with multiple sclerosis.
END OF INTERVIEW
This information is intended for additional research purposes only. It is not to be used as a prescription or advice from Ivanhoe Broadcast News, Inc. or any medical professional interviewed. Ivanhoe Broadcast News, Inc. assumes no responsibility for the depth or accuracy of physician statements. Procedures or medicines apply to different people and medical factors; always consult your physician on medical matters.
If you would like more information, please contact:
Augusto Miravalle
augusto.miravalle@neurology.ufl.edu
Rossana Passaniti
Sign up for a free weekly e-mail on Medical Breakthroughs called mFirst to Know by clicking here.
