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Multiple Sclerosis CE/CME ACCREDITED Watch Time: 33 mins

touchMDT Raising the profile of cognitive impairment in the diagnosis and management of relapsing MS: Multidisciplinary perspectives

Watch leading specialists discuss the importance of addressing cognitive impairment in the diagnosis and management of relapsing MS.

 Overview & Learning Objectives

An MDT considers the diagnosis and management of patients with relapsing MS with a focus on cognitive impairment
Neurologist and Clinical Psychologist/MS Educator
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Identifying relapsing MS earlier Prof. M Freedman, Dr R Kalb

A neurologist and a clinical psychologist specialized in MS care, support and education for individuals in the MS community, discuss the importance of early diagnosis of relapsing MS for improved long-term patient outcomes.

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Neurologist, Advanced Practice Clinician and Clinical Psychologist/MS Educator
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Oral DMTs in the management of relapsing MS Prof. M Freedman, Ms A Perrin Ross, Dr R Kalb

A neurologist, an advanced practice clinician and a clinical psychologist specialized in MS care, support and education for individuals in the MS community, discuss the current treatment landscape for relapsing MS and how oral DMTs can improve patient outcomes.

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Neurologist, Neuropsychologist, Advanced Practice Clinician and Clinical Psychologist/MS Educator
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Cognitive dysfunction in relapsing MS Prof. M Freedman, Prof. D Langdon, Ms A Perrin Ross, Dr R Kalb

Four specialists from the MDT discuss how symptoms associated with cognitive dysfunction can be monitored and managed in patients with relapsing MS

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Neurologist and Clinical Psychologist/MS Educator

A neurologist and a clinical psychologist specialized in MS care, support and education for individuals in the MS community, discuss the importance of early diagnosis of relapsing MS for improved long-term patient outcomes.
Expert Spotlight
Prof. Mark Freedman
University of Ottawa, Ottawa Hospital Research Institute, ON, Canada
Dr Rosalind Kalb
Can Do Multiple Sclerosis, Avon, CO, USA

Watch Prof. Mark Freedman and Dr Rosalind Kalb share their expert insights on the importance of early diagnosis of relapsing MS and the impact initiating treatment earlier can have on long-term patient outcomes.

Listen on the go

 Learn more Back to MDT Hub Time: 10:08
 
Neurologist, Advanced Practice Clinician and Clinical Psychologist/MS Educator

A neurologist, an advanced practice clinician and a clinical psychologist specialized in MS care, support and education for individuals in the MS community, discuss the current treatment landscape for relapsing MS and how oral DMTs can improve patient outcomes.
Expert Spotlight
Prof. Mark Freedman
University of Ottawa, Ottawa Hospital Research Institute, ON, Canada
Ms Amy Perrin Ross
Loyola University Medical Center, Maywood, IL, USA
Dr Rosalind Kalb
Can Do Multiple Sclerosis, Avon, CO, USA

Watch Prof. Mark Freedman, Ms Amy Perrin Ross and Dr Rosalind Kalb share their expert insights on the current treatment landscape for relapsing MS and how oral DMTs can help to improve patient outcomes.

Listen on the go

 Learn more Back to MDT Hub Time: 10:32
 
Neurologist, Neuropsychologist, Advanced Practice Clinician and Clinical Psychologist/MS Educator

Four specialists from the MDT discuss how symptoms associated with cognitive dysfunction can be monitored and managed in patients with relapsing MS
Expert Spotlight
Prof. Mark Freedman
University of Ottawa, Ottawa Hospital Research Institute, ON, Canada
Prof. Dawn Langdon
Royal Holloway, University of London, London, UK
Ms Amy Perrin Ross
Loyola University Medical Center, Maywood, IL, USA
Dr Rosalind Kalb
Can Do Multiple Sclerosis, Avon, CO, USA

Watch Prof. Mark Freedman, Prof. Dawn Langdon, Ms Amy Perrin Ross and Dr Rosalind Kalb share their expert insights on the impact of cognitive dysfunction in relapsing MS, and how to best assess and manage the associated cognitive symptoms.

Listen on the go

 Learn more Back to MDT Hub Time: 12:00
 
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Overview & Learning Objectives
Overview

In this activity, experts involved in caring for patients with relapsing multiple sclerosis (MS) share their multidisciplinary perspectives on the importance of early diagnosis, oral disease-modifying therapies (DMTs) as part of the shared treatment decision-making process, and monitoring and managing associated cognitive dysfunction.

This activity is jointly provided by USF Health and touchIME. read more

Target Audience

This activity has been designed to meet the educational needs of neurologists, MS specialists, clinical neuropsychologists, advanced practice clinicians (APCs) and primary care physicians (PCPs) involved in the management of patients with MS globally, with a focus on the USA.

Disclosures

USF Health adheres to the Standards for Integrity and Independence in Accredited Continuing Education.

All individuals in a position to influence content have disclosed to USF Health any financial relationship with an ineligible organization. USF Health has reviewed and mitigated all relevant financial relationships related to the content of the activity.  The relevant relationships are listed below. All individuals not listed have no relevant financial relationships.

Faculty

Prof. Mark Freedman discloses: Advisory board or panel fees from Alexion, Atara Biotherapeutics, Bayer Healthcare, Beigene, Bristol Myers Squibb (Celgene), Clene Nanomedicine, Hoffman La-Roche, Janssen (Johnson & Johnson), McKesson, Merck Serono, Novartis and Sanofi-Genzyme. Research grant from Sanofi-Genzyme Canada. Consultant fees from Alexion, Atara Biotherapeutics, Bayer Healthcare, Beigene, Bristol Myers Squibb (Celgene), EMD Inc., Hoffman La-Roche, Janssen (Johnson & Johnson), Merck Serono, Novartis, Pendopharm and Sanofi-Genzyme. Speaker’s bureau fees from Sanofi-Genzyme and EMD Serono.

Dr Rosalind Kalb has no interests/relationships or affiliations to disclose in relation to this activity.

Ms Amy Perrin Ross discloses: Advisory board or panel fees from Bristol Myers Squibb, EMD Serono, Greenwich Biosciences, Horizon, Janssen, Novartis, Roche and TG Therapeutics. Consultant fees from Alexion, Biogen, Bristol Myers Squibb, EMD Serono, Genentech, Greenwich Biosciences, Horizon, Janssen, Novartis, Roche, Sanofi-Genzyme and TG Therapeutics.

Prof. Dawn Langdon discloses: Grants and research support from Merck and Novartis. Consultant and speaker’s bureau and fees from Bayer, Biogen, Bristol Myers Squibb (Celgene), Merck, Novartis, Roche, Sanofi and TEVA.

Content reviewer

Peer reviewer John Ciotti, MD, has had advisory board relationships with EMD Serono, Genentech and Janssen. All relationships are terminated and he has no financial interests/relationships or affiliations in relation to this activity.

Touch Medical Director

Christina Mackins-Crabtree has no financial interests/relationships or affiliations in relation to this activity.

USF Health Office of Continuing Professional Development and touchIME staff have no financial interests/relationships or affiliations in relation to this activity.

Requirements for Successful Completion

In order to receive credit for this activity, participants must review the content and complete the post-test and evaluation form. Statements of credit are awarded upon successful completion of the post-test and evaluation form.

If you have questions regarding credit please contact cpdsupport@usf.edu 

Accreditations

Physicians

This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through a joint providership of USF Health and touchIME. USF Health is accredited by the ACCME to provide continuing medical education for physicians.

USF Health designates this enduring material for a maximum of 0.75 AMA PRA Category 1 CreditTM.  Physicians should claim only the credit commensurate with the extent of their participation in the activity.

The European Union of Medical Specialists (UEMS) – European Accreditation Council for Continuing Medical Education (EACCME) has an agreement of mutual recognition of continuing medical education (CME) credit with the American Medical Association (AMA). European physicians interested in converting AMA PRA Category 1 CreditTM into European CME credit (ECMEC) should contact the UEMS (www.uems.eu)

Advanced Practice Providers

Physician Assistants may claim a maximum of 0.75 Category 1 credits for completing this activity. NCCPA accepts AMA PRA Category 1 CreditTM from organizations accredited by ACCME or a recognized state medical society.

The AANPCP accepts certificates of participation for educational activities approved for AMA PRA Category 1 CreditTM by ACCME-accredited providers. APRNs who participate will receive a certificate of completion commensurate with the extent of their participation.

Date of original release: 21 March 2022. Date credits expire: 21 March 2024.

If you have any questions regarding credit please contact cpdsupport@usf.edu

Learning Objectives

After watching this activity, participants should be better able to:

  • Evaluate key characteristics when diagnosing relapsing MS and demonstrate knowledge of the underlying pathophysiology
  • Recall the current treatment landscape for relapsing MS with a focus on evidence-based clinical recommendations for oral DMTs to inform shared treatment decision-making
  • Recognize the importance of monitoring cognitive dysfunction in patients with MS and guide management strategies as needed
Faculty & Disclosures
Prof. Mark Freedman

University of Ottawa, Ottawa Hospital Research Institute, ON, Canada

Mark Freedman is Professor of Medicine in the field of neurology at the University of Ottawa, as well as Director of the Multiple Sclerosis Research Unit at the Ottawa Hospital, General Campus and a senior scientist at the Ottawa Hospital Research Institute. read more

He holds specialist certification in Quebec (CSPQ) and all of Canada as a Fellow of The Royal College of Physicians (Canada). Prof. Freedman is a Fellow of both the American Neurological Association (FANA) and the American Academy of Neurology (FAAN).

Prof. Freedman has published over 300 papers, 500 abstracts as well as numerous books and book chapters, and has been invited to give hundreds of lectures and presentations nationally and internationally.  

His extensive research includes the areas of molecular neurochemistry, cellular immunology, neuroimmunology, cell-based therapeutics and clinical studies in multiple sclerosis (MS). His current research is focused still on cell-based therapies as well as biomarkers for MS. Prof. Freedman was the lead investigator in the Canadian Bone Marrow Transplant Study in MS, is currently the head of the Canadian Mesenchymal Stem Cell Transplantation in MS study (MESCAMS) and co-director of the International Mesenchymal Stem Cell Transplantation in MS Study Group. 

Prof. Freedman has over 35 years of experience in the management of patients with MS and has been the principal investigator on over a hundred clinical trials with new therapeutic agents for MS. He has experience from serving on several research study steering committees as well as data safety monitoring boards. He serves on the editorial boards for several journals including the Multiple Sclerosis Journal and Multiple Sclerosis and Related Disorders. He has also served on several national and international committees, is a past president of the Canadian Network of MS Clinics and is currently President-Elect of the Americas Committee for Treatment and Research in MS (ACTRIMS).

Prof. Mark Freedman discloses: Advisory board or panel fees from Alexion, Atara Biotherapeutics, Bayer Healthcare, Beigene, Bristol Myers Squibb (Celgene), Clene Nanomedicine, Hoffman La-Roche, Janssen (Johnson & Johnson), McKesson, Merck Serono, Novartis and Sanofi-Genzyme. Research grant from Sanofi-Genzyme Canada. Consultant fees from Alexion, Atara Biotherapeutics, Bayer Healthcare, Beigene, Bristol Myers Squibb (Celgene), EMD Inc., Hoffman La-Roche, Janssen (Johnson & Johnson), Merck Serono, Novartis, Pendopharm and Sanofi-Genzyme. Speaker’s bureau fees from Sanofi-Genzyme and EMD Serono.
Dr Rosalind Kalb

Can Do Multiple Sclerosis, Avon, CO, USA

Rosalind Kalb, PhD, is a clinical psychologist who has specialized in multiple sclerosis (MS) care and education for close to 40 years. read more

After receiving her doctorate from Fordham University in 1977, she began her career in MS, providing individual, group, and family therapy at the Medical Rehabilitation Research and Training Center for MS at the Albert Einstein College of Medicine and then at the MS Comprehensive Care Center in White Plains, New York.

Dr Kalb joined the National MS Society in 2000, creating online resources and educational materials for individuals and families living with MS and healthcare professionals, until 2017. She currently serves as Senior Programs Coordinator for Can Do Multiple Sclerosis, helping to develop and implement health and wellness programmes for the MS community. 

Dr Kalb is senior author of Multiple Sclerosis for Dummies (2nd edition), and co-author of Multiple Sclerosis: Understanding the Cognitive Challenges. In addition, she has edited two books – Multiple Sclerosis: The Questions You Have; The Answers You Need, now in its 5th edition, and Multiple Sclerosis: A Guide for Families, now in its 3rd edition.

Dr Rosalind Kalb has no interests/relationships or affiliations to disclose in relation to this activity.
Ms Amy Perrin Ross

Loyola University Medical Center, Maywood, IL, USA

Amy Perrin Ross, APN, MSN, CNRN, MSCN, is a neuroscience program coordinator and is board certified as a neuroscience nurse. As an advanced practice nurse, she has coordinated numerous clinical research trials in multiple sclerosis (MS) and dementia. read more

She is a past president of the International Organization of Multiple Sclerosis Nurses and recipient of the June Halper Award for Excellence in MS Nursing, representing leadership and creativity in the care of people with MS and their families, an award that signifies an energy of purpose to provide the most up-to date comprehensive care possible. 

Ms Perrin Ross has authored articles and book chapters on MS. She has been a clinical nurse consultant with the National Multiple Sclerosis Society, a member of the Health Care Advisory Council for the Multiple Sclerosis Association of America, and a board member of the Consortium of Multiple Sclerosis Centers. Ms Perrin Ross has been an invited speaker at national and international meetings and conferences.

Ms Amy Perrin Ross discloses: Advisory board or panel fees from Bristol Myers Squibb, EMD Serono, Greenwich Biosciences, Horizon, Janssen, Novartis, Roche and TG Therapeutics. Consultant fees from Alexion, Biogen, Bristol Myers Squibb, EMD Serono, Genentech, Greenwich Biosciences, Horizon, Janssen, Novartis, Roche, Sanofi-Genzyme and TG Therapeutics.
Prof. Dawn Langdon

Royal Holloway, University of London, London, UK

Dawn Langdon is Professor of Neuropsychology at Royal Holloway University of London. She is registered as both a neuropsychologist and a health psychologist. read more

Prof. Langdon is a Fellow of the British Psychological Society and neuropsychology lead on a number of multinational trials for the pharmaceutical industry.

Prof. Langdon has worked extensively on psychological aspects of multiple sclerosis (MS), including measurement of cognition and its relation to pathology and other disease variables. She is investigating how risks and benefits of MS medication are best communicated to patients, including a successful randomized control trial comparing the new protocol to consultation as usual.

Prof. Dawn Langdon discloses: Grants and research support from Merck and Novartis. Consultant and speaker’s bureau and fees from Bayer, Biogen, Bristol Myers Squibb (Celgene), Merck, Novartis, Roche, Sanofi and TEVA.
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This Activity Is Funded By:

An independent medical education grant from Bristol Myers Squibb.
This medical education is jointly provided by USF Health and touchIME.

The information provided by this CME activity is for continuing education purposes only and is not meant to substitute for the independent medical/clinical judgment of a healthcare provider relative to diagnostic and treatment options of a specific patient’s medical condition.

USF is an Equal Opportunity / Affirmative Action / Equal Access Institution.

USF Health is accredited by the Accreditation Council for Continuing Medical Education, the American Nurses Credentialing Center and the Accreditation Council for Pharmacy Education to provide continuing education to healthcare professionals. As an accredited provider, USF Health is required to disclose personal information to relevant accredited bodies that certify CME to process credits/contact hours, comply with reporting requirements, and for internal recordkeeping and regulatory purposes. USF Health does not share or sell any individual’s contact information or unique identifiers to any commercial supporter, advertiser, or third party without the specific permission of the individual.

Unapproved products or unapproved uses of approved products may be discussed by the faculty; these situations may reflect the approval status in one or more jurisdictions. The presenting faculty have been advised by touchIME and USF Health to ensure that they disclose any such references made to unlabelled or unapproved use. No endorsement by touchIME or USF Health of any unapproved products or unapproved uses is either made or implied by mention of these products or uses in touchIME or USF Health activities. touchIME and USF Health accept no responsibility for errors or omissions.

This content is intended for healthcare professionals.

Date of original release: 21 March 2022. Date credits expire: 21 March 2023.

This content is intended for healthcare professionals only. Please confirm that you are a healthcare professional.

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Question 1/5
Patients may present to primary care during the prodromal phase before it is possible to confirm a diagnosis of MS via established criteria. Which of the following are typical symptoms of the MS prodrome?

MS, multiple sclerosis.
 Correct

Clinical onset of MS usually occurs between the ages of 20 and 50 years, but the prodromal phase could begin many years earlier and its characteristics are likely to vary between individuals.1

MS-associated CNS damage leads to a wide range of symptoms, including changes in cognitive functioning.2 The high mental health burden observed in the prodromal phase of MS could reflect a threshold of inflammation being reached that increases the risk of depression.1

CNS, central nervous system; MS, multiple sclerosis.

References

  1. Makhani N, Tremlett H. Nat Rev Neurol. 2021;17:515–21.
  2. Kalb R, et al. Mult Scler. 2018;24:1665–80.
Question 2/5
Your patient has noted recent cognitive changes. Which of the following oral drug classes may help to improve cognitive function?

Nrf2, nuclear factor erythroid 2-related factor 2; S1PR, sphingosine-1-phosphate receptor.
 Correct

In post hoc, exploratory analyses of the SUNBEAM study, treatment of patients with relapsing MS with the S1PR modulator ozanimod (0.92 mg) was associated with modestly beneficial effects on cognitive processing speed, measured as part of a secondary endpoint using the SDMT. A greater percentage of ozanimod‒treated participants had clinically meaningful improvements in SDMT scores vs IFN β-1a at month 12 (35.6% vs 27.9%).1 The effects of ozanimod on SDMT are being further evaluated in ongoing phase III trials (DAYBREAK, NCT02576717 and ENLIGHTEN, NCT04140305).1

In the phase IV GOLDEN trial, participants with RRMS and cognitive impairment in both treatment groups, those receiving the first-generation S1PR modulator, fingolimod, or IFN β-1b, showed improvements in all cognitive parameters assessed.2

IFN, interferon; MS, multiple sclerosis; RRMS, relapsing–remitting multiple sclerosis; S1PR, sphingosine-1-phosphate receptor; SDMT, Symbol Digit Modalities Test.

References

  1. DeLuca J, et al. Mult Scler Rel Dis. 2021;48:102673.
  2. Comi G, et al. J Neurol. 2017;264:2436–49.
Question 3/5
What is the primary reason to consider oral vs injectable DMTs as part of shared treatment decision-making for people with relapsing MS?

DMT, disease modifying therapy; MS, multiple sclerosis.
 Correct

Shared decision-making is an important process to select appropriate diagnostic tests, treatment, and disease management strategies based on clinical evidence and the values and preferences of patients.1

Clearly discussing the impact of treatment on quality of life and potential long-term outcomes while having open lines of communication with the patient will improve the relationship and foster treatment adherence.1,2

References

  1. Ben-Zacharia A, et al. Int J MS Care. 2018;20:287–97.
  2. Zanga G, et al. Ther Adv Neurol Disord. 2021;14:17562864211031099.
Question 4/5
Which of the following is a 15-minute assessment of cognitive function in MS that also includes the SDMT?

BICAMS, Brief International Cognitive Assessment for MS; CFSS, Cognitive Functioning Self-Assessment Scale; MS, multiple sclerosis; MSNQ, Multiple Sclerosis Neuropsychological Questionnaire; PASAT, Paced Auditory Serial Addition Test; SDMT, Symbol Digit Modalities Test.
 Correct

BICAMS can be used to detect cognitive dysfunction in 15-minutes in adults with MS, specifically in areas of information processing speed, and immediate verbal and visual recall.1,2 

BICAMS has been widely applied across cultures and languages to assess cognition in MS. BICAMS offers a feasible, cost-effective means of assessing cognition in MS worldwide.2

BICAMS, Brief International Cognitive Assessment for Multiple Sclerosis; MS, multiple sclerosis.

References

  1. Langdon DW, et al. Mult Scler. 2012;18:891–8.
  2. Corfield F, Langdon D. Neurol Ther. 2018;7:287–306.
Question 5/5
Your patient is a 44-year-old man with MS. He has been receiving interferon injections since his diagnosis 7 years ago. He is happy with his current treatment regime; however, he has reported feeling overwhelmed by his usual tasks at work and his support partner has noted difficulty keeping up with conversations. Based on currently available evidence, what are your next steps?

MS, multiple sclerosis.
 Correct

A more comprehensive neuropsychological assessment (including assessment of mood) is recommended for any adult who reports problems at work or poor performance reviews.

There is strong consensus that cognition declines in patients over longer (10–20 years) periods of time; however, adults with early cognitive impairment tend to show greater decline. Cognitive impairment predicts limitations in the workplace and in social settings independent of level of physical disability. Information processing and memory are the most commonly affected cognitive domains in MS. Studies have demonstrated the importance of identifying a person’s areas of deficit to determine which remedial interventions are likely to be of greatest benefit and in which order they should be provided.

MS, multiple sclerosis.

Reference

Kalb R, et al. Mult Scler. 2018;24:1665–80.

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