Multiple Sclerosis: Diagnosis, Medical Management, and
Rehabilitation
From The New England Journal
of Medicine, December 14, 2000
In this excellent resource for physicians involved in the
care of patients with multiple sclerosis, most of the chapters are authoritative
and well written. The material is presented clearly and concisely; well-designed
tables help to summarize the main points of each chapter. The index is well laid
out and easy to use. Important scales used in the evaluation of patients or in
clinical research are presented in an easily understandable manner, and the
advantages and disadvantages of each scale are thoughtfully considered. In
addition, the reference lists are sufficiently detailed, and the cited works are
simple enough to find, that readers can easily identify and seek out the most
important publications in the vast literature on multiple sclerosis. There are
two specific areas, however, in which the book could be improved in future
editions.
The first is the epidemiology of multiple sclerosis. The chapter on this topic is focused on only a small part of the available information: it is devoted largely to older literature about the worldwide distribution of the disease and the few (and controversial) alleged epidemics of multiple sclerosis. Newer information on the natural history of multiple sclerosis is, for the most part, ignored. There also needs to be a broader consideration of other epidemiologic aspects of multiple sclerosis, such as the prognosis for substantial disability (and factors that may alter this prognosis), genetic factors, the likelihood that multiple sclerosis will develop after an initial episode of demyelination (and the use of magnetic resonance imaging and other techniques in estimating this likelihood), the effect of multiple sclerosis on life expectancy, the relation of attacks of multiple sclerosis to nonspecific viral infections, and the relation between such attacks and conditions such as pregnancy.
The second deficiency is in the coverage of treatment. It seems unfortunate that the editors have divided the discussions of treatment into separate chapters according to relapsing and progressive forms of the disease. Because many of the available treatments can be used for both forms of multiple sclerosis, it would have been preferable to have these therapies considered in a single chapter. That way, the quality of the evidence in favor of each therapy could have been considered separately, and specific recommendations regarding the appropriate use of each agent could have been made. As presented in this book, the information on treatment is a bit confusing. For example, the fact that interferon beta and glatiramer acetate are considered primarily in the chapter on relapsing forms of multiple sclerosis suggests that these treatments are inappropriate (or of only emerging status) for progressive forms. By contrast, the principal discussion in the chapter on treatment of progressive forms of multiple sclerosis is confined to immunosuppressive agents such as azathioprine, cladribine, cyclophosphamide, cyclosporine, methotrexate, glucocorticoids, and plasma exchange. This suggests that these treatments (unlike interferon beta and glatiramer acetate) are of established value in the management of progressive multiple sclerosis. However, the value of many of these therapeutic approaches remains to be established. Indeed, these treatments, although widely available, are typically prescribed for only a small minority of patients with multiple sclerosis, and in some cases the evidence in favor of the so-called emerging therapies is substantially better than it is for the former treatments. Moreover, certain discussions regarding individual immunosuppressive treatments in the chapter on progressive forms seem to suggest that some of these agents (e.g., azathioprine) are actually more appropriate for the treatment of relapsing forms. Whereas I agree with most authorities that immunomodulatory therapy should be started soon after multiple sclerosis is diagnosed, agreement is not universal about which particular therapy to start. Given this circumstance, it would have been preferable to remove any general considerations of whom to treat and when to begin treatment from the discussions of specific agents and to include them elsewhere instead.
In summary, this is an excellent and comprehensive book on a wide range of topics relating to multiple sclerosis. The discussions are, in general, thorough and accurate and the information easily accessible. It will be a welcome addition to the library of any physician with an interest in the diagnosis and management of multiple sclerosis.
Douglas S. Goodin, M.D.
Copyright © 2000 Massachusetts Medical Society. All rights reserved. The New
England Journal of Medicine is a registered trademark of the MMS.
