Comorbidities and MS: Patricia Melville, NP-C

Aims of the session (0:21)

The aims of this piece are to:

• Identify common comorbidities in MS
• Examine the importance of comorbidities in MS
• Use critical thinking in management of comorbidities and use of disease-modifying therapies (DMTs)
• Educate and counsel people living with MS (PwMS) on the importance of lifestyle modifications to prevent comorbidities

Key messages

(0:52) Comorbidities are defined as any burden of illness other than the specific disease itself (MS in this case). Current studies are looking at comorbidities in conjunction with the following:

• Genetic predisposition, in particular the HN1A gene
• Environmental factors
• Inflammation
• The use of DMTs

(1:19) The highest prevalence of comorbidities reported in PwMS from North American and European MS cohorts are:

• Depression 23.7%
• Anxiety 21.9%
• Hypertension 18.6%
• Hyperlipidemia 10.9%
• Chronic lung disorder 10%

The highest prevalence in regards to immune-medicated disorders are Thyroid and Psoriasis.

(1:58) PwMS have three times the mortality rate compared to the general population, and their lifespan is 6–7 years shorter.

A Canadian study has demonstrated that MS patients with more than three comorbidities had a higher relapse rate (Kowalec, 2017) and another Canadian study of 10,698 patients showed that 50% had more than one comorbidity.

A Swedish study showed higher Expanded Disability Status Scale (EDSS) score in female PwMS with the comorbidity of depression (Binzer, 2019). Whilst the reason is not clear, Patricia queried whether this could be due to negative health behaviours.

Patricia also cited a meta-analysis of seven studies of polypharmacy (more than five medications) and MS patients which showed that 15–59% identified as having one or more comorbidities.

The management approach should be to reduce modifiable risk factors and involve the multidisciplinary team (MDT), with the aim of improving quality of life on an individual basis. This should involve considering relevant guidance such as:

• Practice guidelines from the American Academy of Neurology (AAN)
• Guidelines from ECTRIMS (Montalban, 2018) regarding comorbidities and DMTs
• The guidance provided for each individual DMT

Conclusion (2:32)

The take home message of the session was:

‘Recognising and managing comorbidities early in the disease will be very beneficial.’

In summary it can be said that:

• Comorbidities are more common in people with MS
• It is necessary to address lifestyle management to optimise quality of life
• Those with MS should engage in wellness programmes
• Management should be a multi-disciplinary approach
• Shared decision-making should be used for DMT management

References

1. Kowalec K, ‘Comorbidity increases the risk of relapse in multiple sclerosis: a prospective study’, ECTRIMS Online Library. Kowalec K. 10/27/17; 199885; P1865
2. Binzer S, McKay KA, Brenner P, Hillert J, Manouchehrinia A, ‘Disability worsening among persons with multiple sclerosis and depression: A Swedish cohort study’, Neurology Dec 2019, 93 (24) e2216-e2223; DOI: 10.1212/WNL.0000000000008617
3. Rae-Grant A, Day GS, Marrie RA, et al. Practice guideline recommendations summary: Disease-modifying therapies for adults with multiple sclerosis: Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology [published correction appears in Neurology. 2019 Jan 8;92(2):112]. Neurology. 2018;90(17):777‐788. doi:10.1212/WNL.0000000000005347
4. Montalban X, Gold R, Thompson AJ, et al. ECTRIMS/EAN Guideline on the pharmacological treatment of people with multiple sclerosis [published correction appears in Mult Scler. 2020 Apr;26(4):517]. Mult Scler. 2018;24(2):96‐120. doi:10.1177/1352458517751049

Further information

• Blog by Prof Gavin Giovannoni on prescribing of DMTs and comorbidities
• 2018 CMSC presentation: ‘Certain comorbidities more common amongst those with MS’
• Watch the full CMSC presentation online via NeurologyLive