Multiple sclerosis

Part II: What neurologists should look out for in 2023

The next 12 months look set to be big ones in neurology, with major developments predicted across all areas of the specialty.

The limbic asked three experts to share their tips for things to watch in 2023. [ You can read Professor Simon Lewis’ and Associate Professor Richard Stark’s predictions on developments in headache and Parkinson’s here.]

Professor Tomas Kalincik is tipping a big year for the specialty, starting with the pending redefinition of the classification of multiple sclerosis.

Associate Professor Tomas Kalincik

Professor Tomas Kalincik

Already in progress, the rethink is based on steering away from the clinical phenotypic presentation towards something that looks at the pathogenetic phases of different processes in MS.

“It’s really exciting and more closely related to where we want our drugs to work,” says Professor Kalincik, head of the Clinical Outcomes Research (CORe) Unit at the University of Melbourne.

“The implications of this could potentially be massive, from the regulatory implications and available treatments to patients with various presentations and therefore the ability of clinicians to control the presentation and progression of the disease much better.”

Professor Kalincik says he’ll also be closely watching the series of RCTs on hematopoietic stem cell transplantation (HSCT) in MS.

Results from at least some of the these are expected to start coming out, along with data from studies comparing ocrelizumab with rituximab.

“It will be very interesting to see what the verdict is, particularly given the vast difference in cost,” he says.

Similarly, results are expected to emerge from industry-run trials examining extended dosing intervals for natalizumab, which could lead to more individualised treatment approaches.

“Another area which has been neglected for a long time is the limited number of therapies available to kids with MS,” Professor Kalincik says.

“We really should be working to expedite acceptance and approval of available treatments to these younger patients, without having to go through the whole process again with RCTs… so expect that to continue at a dramatic pace.”

MOGAD ‘a space to watch’

Professor Kalincik will also be keeping a close eye on developments in MOGAD, both in adults and in paediatric populations.

With the ink still drying on the first published guideline on the management of MOGAD, he says work is already underway on an update to include newer biological therapies.

“That’s a space to watch and hopefully something with some emerging evidence about the timing of treatment and finding patients who may require more long term therapy, but it should lead to improvements in the quality of care that we are providing.”

Beyond that, developments in neuroimmunology and neurological genotyping of patients to guide therapy are continuing apace.

“We can now see tools emerging that in the future will enable that approach, which has been a dream of many neurologists for a long time,” Professor Kalincik says.

“It will allow us to target treatments where we know their mechanism of action in relation to the disfunction in the immune system.”

Finally, the heavy work of the past few years in using imaging to define pathogenesis underlying progression in MS is expected to bear fruit, he says.

“A lot of work has been done and it will be interesting to see how long it takes these methods which are already being used in studies to make their way into written protocols in guiding clinical care.”

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