If Carla Keesecker had been diagnosed with
multiple sclerosis (MS) 20 years ago, her physician would have looked at
her and said, “There is nothing we can do for you.”
But today, 10 years after her diagnosis, Keesecker can recite the names of the drugs she has taken as if she
were a professional health care provider: Avonex, Rebif, Copaxone,
Tysabri and the newly approved Gilenya, which is the first oral
medication for MS. “It took trial and error to find the medication with
the fewest side effects,” she said.
She is a living example of how far medicine has come in a very short time.
The first challenge: Compliance
Keesecker admits that when she was first diagnosed, she immediately
envisioned the worst-case scenario. “I knew nothing about the disease
and I was terrified,” she said. “The only person I had met with MS was
in a wheelchair. I had to go through a very steep learning curve."
The first three medications she tried were all injections intended
to be self-administered. All three had significant side effects,
including fatigue and stiffness. “I tried to inject myself but it’s hard
to give yourself a shot, especially if the shot makes you feel bad,”
she said.
Corby says that’s a major problem with some MS medications. “When
taking the drug makes you feel worse, we have patients who don’t want to
take it,” he said. “So compliance really suffers.”
The next challenge: Managing risk
Keesecker then tried Tysabri, a drug that is administered
intravenously on an outpatient basis. She was pleased with the results,
until she learned that she was carrying the John Cunningham (JC) virus,
which can trigger a rare and usually fatal disease for patients taking
the drug.
“If you are positive for the JC virus, the risk of taking Tysabri
changes over time,” said Corboy. “We know it increases in the third
year.”
Twenty-three months after she started Tysabri, Keesecker decided
the risk was too great. She quit the drug. But by this time, the Food
and Drug Administration had approved Gilenya, a drug that MS patients
can take orally.
“It’s so much easier,” said Keesecker. “I just take it with my fish oil capsules at breakfast!”
“Patients no longer have to stick a needle in themselves to deliver
a drug,” said Corboy. “This is such a step forward, because the
improvement in compliance is dramatic.”
But Gilenya also has the potential for significant side effects. “With hope comes more uncertainties,” Corboy said.
Future challenges: Personalize, repair, prevent
Corboy believes the future of MS treatment is about to arrive, with
the use of an individual patient’s genetic and related data to
determine the risks and benefits of each medication and personalize
treatment.
He might direct one patient to an interferon—a protein that
triggers the immune system—because he sees genetic indicators that it
will work well for that person. He might steer another away from
Tysabri, because it poses a high risk to that patient’s health due to
prior exposure to the JC virus.
Personalized treatment like this was once considered “science fiction,” said Corboy. “Now it is science.”
Corboy hopes stem cells will take MS care to the next plateau—the
development of drugs that can actually repair a nervous system damaged
by MS. By the end of his career, he would like to see another giant
step.
"I believe that we will be able to identify which people are going
to develop MS before they have it and stop them from getting the
disease,” he said.
It’s that kind of bold thinking that keeps Carla Keesecker going.
“MS research holds so much hope for people like me,” she said. “That’s
what gives me a positive outlook.”