Polly: Where do you think the next breakthrough drug for MSers will come from?
Professor Gavin Giovannoni, Neurologist: Breakthrough drug? So I mean we’ve got a large number of drugs now and what we do know now is the best results are with the most effective therapies. But the most effective therapies come with risks. As you know with Tysabri and Ocreluzimab, it’s that infection of the brain called PML. With Alemtuzumab or Lemtrada the risks are secondary auto-immunity. So the next breakthrough really is going to be drugs that are as effective as those, without risks. So I think the next breakthrough’s going to be a very effective anti-inflammatory drug that’s safer to use, which means many more people will want to use it early in the disease, because it’s safe.
So that’s to me the breakthrough, is a safe anti-inflammatory. Then in progressive MS we need to now think about how do we – because all the anti-inflammatory therapies haven’t really worked in progressive MS yet – so what we probably need to do is combination, is add on a drug, what we call neuroprotective therapy, and I think the next breakthrough’s going to be a combination for progressive MS. We’ll have an anti-inflammatory plus something else to slow down the progression of the disease. I say slow down, because I don’t want to raise people’s expectation and say we’re going to stop the progression, but I think even if we slow down the progression, it will make a big difference to people’s lives.
Polly: Okay, that leads on quite well to the next question, which is why don’t the newest tranche of disease modifying drugs work for secondary progressive MS or PPMS?
Professor Gavin Giovannoni: So why don’t they work for progressive… Well, I think it’s the way we define the disease. So my personal opinion is progressive MS doesn’t just pop up at some point in time, it’s there from the very beginning. And I think what underlies progressive MS is progressive brain atrophy, this shrinkage of the brain, this volume loss. And if you look at studies, this brain volume loss is occurring from the very earliest stages of the disease, from the first clinical attack or even before, people before their first clinical attack have got brain volume loss. So by the time you present with progressive MS you’ve already lost a large number of neurons in that particular pathway. So trying to protect the pathway when it’s lost most of its neurons is very difficult. So I actually think we need to go back and start treating early disease with drugs that protect the brain to prevent progressive disease. So I think the reason why these drugs haven’t worked is because we’re trying them too late in the course of the illness, we should try them earlier. Or, we need to use different strategies. So anti-inflammatory strategies on their own are not effective, we have to add in the combination strategy. So I’m quite confident that when we start thinking about combination therapies we’ll start to have an impact in progressive MS.
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Professor Gavin Giovannoni has an MBBCh, PhD, FCP (Neurol., SA), FRCP, FRCPath amongst his qualifications. He is the Chair of Neurology at Barts and The London School of Medicine. His research interests have focused around multiple sclerosis and inflammatory disorders of the central nervous system. His teaching focuses on clinical neurology and neuroimmunology.