The first challenge involves making a quick, accurate diagnosis. The next step is to decide whether or not it is necessary to start treatment immediately or to take a calculated risk and first follow the spontaneous course of the disease. This can only be done with the full cooperation of the patient, using magnetic resonance imaging of the brain (MRI) as an additional decision-making tool. Once the need for treatment has been established, the next step is to present the various options available, the benefits and inconveniences of each treatment, their potential effectiveness, and the fact that we still unfortunately don’t know in advance if a given patient will respond to a given treatment. The neurologists must express their honest opinion and help their patient make a choice. The decision will be made based on the patient’s preferences, as well as on the specific positive and negative aspects of the prognosis. Follow-up of the treatment selected will require regular blood tests, meticulous neurological examinations and brain imaging at regular intervals. The neurologist must take into consideration the most obvious symptoms and those perceived by the patient, as well as symptoms which are more difficult to detect.
A significant difficulty for both neurologists and patients consists in discriminating between the symptoms directly related to multiple sclerosis and others related to additional issues including headaches, migraines, tendinitis and changes in overall health. Potential pregnancies must also be discussed with MS women based on the current treatment and the overall evolution of the disease…
Another issue which is sometimes difficult to manage is the discovery, based on clinical or brain imaging data, that the patient’s current treatment is not working and that another treatment must be tried. A “zero tolerance” approach is not always possible and it will be necessary to determine what can be tolerated based on the stage of the disease. A change in treatment can be difficult to accept and, generally speaking, second-line treatment will be riskier, require more biological and other testing, and involve a more demanding therapeutic load. In this case in particular, the reasons for the change in treatment must be fully explained to the patient. They must also be informed that the purpose of the new treatment is to prevent the disease from worsening over the next 10 to 20 years and that current treatments cannot repair existing lesions.
The neurologist will also be required to decide whether vaccines are useful and harmless, whether medicines should be taken for other health problems, whether or not surgery is required for issues unrelated to the neurological disease, and what action should be taken when other transitory and non-critical symptoms appear. Other sources of anxiety for patients include understanding how their illness is evolving, what they can look forward to, what they will have to be concerned about in the future, their career and family choices, and the genetic risk for their children and family members. The neurologist must therefore be able to provide information, explain and re-explain in layman’s terms, maintain the treatment under way, downplay issues which are unimportant, and provide a reassuring presence over the long-term by always being available. They must also be willing to admit that they aren’t able to answer every question...in the end, the goal is to exchange and interact constantly to help patients live better and to develop a relationship of mutual respect.
Professor C. Sindic