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World Congress in Montreal, 2008

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On September 17-20, 2008, the European, North American, and Latin American Committees for Treatment and Research in MS held a combined meeting in Montreal.  There are some of the presentations that I found interesting.

There were many presentations on treatment of MS. 
The most interesting presentation to me was the results of the study of Rituximab in primary progressive MS.  We currently don't have any treatments that are effective in progressive MS, although mitoxantrone may have some limited usefulness in secondary progressive disease.  Rituximab is an antibody that gets rid of B cells, one of the types of white blood cells, and it looks promising for treatment of relapsing-remitting MS. 
The study overall was negative with 38% of the untreated patients worsening compared to 30% of the treated patients.  There were some encouraging signs that suggest this treatment should be further investigated.  Patients who were younger than 51 years or who had enhancing lesions on their MRI scans did significantly better with treatment. 
There were two studies looking at different doses of glatiramer (Copaxone).  A large study compared double dose with the standard dose, and found no additional benefit from increasing the dose.  A small study done at one center compared the standard every day injections with every other day.  They didn't find any difference between the two doses, but the study wasn't large enough to draw firm conclusions. 
Dr. Fox reported on the Tovaxin (T cell vaccine) study.  This may be of interest since the company that sponsored the study is in the Woodlands, and I have fielded a lot of questions from people interested in the study.  The results were negative, and I don't know whether they plan to proceed with further work on this. 
There were some interesting presentations on aggressive treatments.  High dose chemotherapy to wipe out the immune system followed by bone marrow transplant continues to be studied.  This seems to prevent relapses and enhancing lesions on MRI, but some patients still have progression of disability.  The mortality has decreased to 1.3%, which is still a troublesome level.  A study comparing bone marrow transplant to mitoxantrone treatment is in progress.  This may be a reasonable option for people with very aggressive MS.  Further results from the study with alemtuzumab, an antibody that gets rid of most white blood cells, continue to look interesting.  There are significant risks, but again this might be an option for bad MS. 
Finally, there was a presentation on treatment with stem cells by Dr. Karussis from Greece.  They have treated a small number of MS and ALS patients with stem cells extracted from the patient's own bone marrow.  The MS patients they treated were fairly disabled.  They only had 6 months of followup which is not adequate to assess benefit, but there were no significant problems with the treatment.  

There were also some interesting scientific results which don't have immediate application to treatment
There was a session on degeneration in MS.  In recent years, some have argued that the primary problem in MS was degeneration of nerve cells or myelin cells, and the inflammation was secondary.  If this is true, all of the treatments that we are working on now will have limited benefit.  The consensus of opinion in this session was that the immune damage occurs first followed by degeneration. 
My own research interest is in the relation of Epstein-Barr virus and MS.  There were several poster presentations that added support to the fact the EBV infection increases the risk of MS.  EBV doesn't appear to directly infect the brain though, so how it might cause disease is unclear.  

J. William Lindsey, MD
University of Texas Multiple Sclerosis Research Group
Houston, Texas

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