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A funny thing happened
on the way to San Francisco. ABILITY editor-in-chief Chet Cooper planned
to fly up from LAX for a few hours to meet with one of the foremost authorities
on multiple sclerosis: Dr. Douglas S. Goodin. But it turned out Cooper
May I have your
attention, please? a voice came over the P.A. system as he sat in
the boarding area. Flight 293 to San Francisco has been cancelled.
That was followed by more good news: There are no more flights to
San Francisco today.
After a few passengers
had full-on tantrums, the airline put them on the local, flying them into
San Jose, and then shuttle-busing them through Palo Alto and San Mateo
up to San Francisco, 45 minutes away.
It was a bumper to
bumper ride. But all was not lost. As sometimes happens, Cooper got a
good seatmate: Melanie Jameson. He told her he was in town to talk with
neurologists at UCSFs Multiple Sclerosis Center. What a weird
coincidence, she replied. I have MS myself! Shed
recently relocated from New York to Northern California, and had yet to
find a local doctor. So he took her along to the interview. Her questions
would be as good as his own, if not better, he reasoned. Jameson would
bring a patients perspective to the conversation about the causes,
treatment, and possible cures of MS, which affects roughly 400,000 people
in the United States.
Chet Cooper: How
would you describe MS?
Dr. Goodin: MS is
an inflammatory disorder of the nervous system that tends to occur in
episodes. So people get symptoms of neurologic dysfunction: blindness,
numbness, weakness, imbalance, trouble with bowel and bladder. It lasts
for a period of weeks to months and they typically remit at the beginning,
and then later on, over the course of the illness, many patients experience
a more steady and insidious progression of their disability, which is
where we call the transition from remitting/relapsing MS to secondary
progressive MS. A few people, not very many, have progressive MS right
from the get-go. But by and large, we think of MS as being these recurrent
inflammatory episodes that affect the brain in a relatively random way.
CC: How would a
doctor evaluate someones symptoms and diagnose MS? There are a lot
of symptoms that could be due to something else.
DG: Well, potentially,
any symptom in the nervous system could be due to MS. As I said, it could
be blindness, numbness, weakness, a whole variety of things. The key to
making a diagnosis is that usually MS patients are young, the typical
age of onset is between the ages of 20 and 40, so that takes it away from
some of the other diseases of the nervous system, like strokes, which
tend to affect an older age group. So if a person comes in and theyre
young, its more likely that youre dealing with something like
MS. This recurrence and then remission, that pattern of illness, is very
characteristic of MS. If a person comes in with that, that ought to at
least be on your mind. Were obviously also helped out by laboratory
tests, MR scans. Now we can image the persons brain and actually
get a very clear picture of what is going on in their central nervous
system. Similarly, spinal fluid can provide us with information that would
not be present in some of the other neurological problems.
CC: Can you take
us through a little bit of the standard procedure for treating MS?
DG: Its not
usually that the person has been suffering from something or having symptoms
for years. They come in with these episodes, so they may come in with
an episode where they, for instance, cant see out of their left
eye, or they can see very little out of their left eye, and its
come on over the course of a week, and now theyre coming to us and
asking our opinion or asking for treatment, or both. And then we will
take a history and say, Have you ever had anything like this before?
And theyll say, Well, there was that one time in college 20
years ago or 10 years ago or five years ago when I woke up in the morning
and my whole left side had gone to sleep. I couldnt feel anything
in my arm or leg. It was there for a week and it went away. I was told
by the doctors that it was stress and finals. I didnt think anything
more about it. That would be an important event for us to know about
that would help us make the diagnosis of MS. But usually, in the interim
they have not had any problems. They usually will be functionally normal.
your opinion of the typical drugs used to treat MS? Avonex, Betaseron,
Copaxonethe ABC drugs.
DG: Well, I think
all of us have our own take on the ABC drugswhich ones are more
effective, or less effective. My own view is that the interferons as a
class, of which there are three, Avonex (Biogen), Betaseron (Berlex),
and Rebif (Serono), have better evidence of being effective than Copaxone
(Teva). That doesnt mean that Copaxone doesnt work as well,
it just means that it hasnt been studied as thoroughly, so I have
less confidence. That makes me use Copaxone relatively less. Other people
are impressed by the fact, and its certainly true, that Copaxone
is very well-tolerated and, in fact, is probably better tolerated than
the interferons. Theyre not as disturbed by the fact that theres
less evidence of it being effective, they like the side-effect profile
and theyre more likely to use Copaxone. I think theres a lot
of individual physician variability on that.
CC: Can you tell
me about the trials that youre doing at UCSF?
DG: UCSF is actually
involved in a lot of trials. One of the trials that Im doing is
looking at Betaseron, which is one of the interferons, in its current
dose, doubling the dose and comparing it to Copaxone. That trials
actually almost over. Were about to take on a couple of trials with
some novel agents that are not currently approved by the FDA but have
very promising results in phase two. One of them has the very catchy name
of FTY720, which just rolls off your tongue. I think it will have another
name when its marketed, though.
FTY720 looks very
promising in phase two, and its an oral treatment, so it would avoid
the injection, so that would be great. Theres another one that is
called Rituximab (Genentech), which is also being used as an anti-cancer
drug, so we have some information on the safety of that. The nice thing
about Rituximab is that it also has great phase two data, but the really
nice thing is, you only inject it once every nine months to a year. So
both those drugs, if they work, which I hope they will, will actually
be a major step forward.
How do these two drugs compare to Tysabri?
DG: Tysabri (Biogen)
has some problems, because of the two people that got a rare, usually
fatal brain infection called multifocal leukoencephalopathy during the
study. Thats made some people a little nervous. The idea of putting
a 22-year old on a drug that could kill him doesnt sound like a
good choice. [i](laughs)[i] So its going to be two or three years
before Im going to feel really comfortable with Tysabris safety
By that time, I think
these other two drugs are going to be on the market. Its usually
very hard to know in phase two how theyre going to look in phase
three. One of the things that was really impressive with Tysabri was that
the phase two study was a big studyinvolving almost 200 patientsand
gave us a really good clue as to what we were going to see in phase three.
The same size study
has been done on these two new drugs, and they have, at least in phase
two, similar efficacy to Tysabri. But they probably have a better side-effect
profile. In other words, FYT720 has actually been used in kidney transplants,
so we have a fair amount of at least short-term data on FTY720, and Rituximabs
currently FDA approved for treatment of some cancers, whereas with Tysabri
we really didnt know. It was brand new. But well see. Both
of the drugs are very potent. I mean, the fact that you only have to use
Rituximab once every nine months means that it works for a long time.
Theres no take-backs. You cant go, Oops!....Continued
in ABILITY Magazine
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