Progress in the Management of Multiple Sclerosis
Multiple Sclerosis (MS) presents a challenge to insurers due to its complex, unpredictable course. MS is a covered condition in “Critical Illness” insurance policies sold in markets across Asia, in the UK and Ireland, South Africa, New Zealand and Australia, and is a significant cause of mortality and morbidity. Consequently, MS features in the daily work of many individuals involved in insurance product design, pricing, underwriting and claims.
MS symptoms arise from a combination of demyelination and neurodegeneration; damage to the insulating coat of the nerve cells and loss of structure and function of the cells respectively. The changes are mediated through activated immune cells migrating into the brain.
Before MRI scanning enabled identification of demyelination, MS was largely diagnosed clinically. Even now, despite the significance of MRI scanning for diagnosis, there is often no direct correlation with the patient’s clinical state.
The clinical pattern observed in the most common MS type, Relapse-Remitting or RRMS, while typical of autoimmune disease, is unusual for a neurological disorder. RRMS involves flare-ups in symptoms every 12 to 24 months with varying levels of recovery. The point at which the pattern changes to a steady progression of symptoms and disability - Secondary Progressive - is variable at 50% in 10 years.1 In the two other sub-types of MS, Primary Progressive and “benign MS”, individuals experience only progression or mild relapses respectively.
The treatment of relapses continues to rely upon high dose steroids. Most of the excitement in the management of MS has centered upon disease-modifying treatments that are intended to decrease relapses and delay disability.
In 1993 Interferon became the first drug licensed for MS, showing improved survival and producing a 30% reduction in relapses over a 20-year period. Experience with the drug made it clear that MRI disease-monitoring was useful and earlier treatment improved outcomes. Since then, the range of drugs available has increased - each with its own action to reduce relapses and MRI disease activity. However, despite these improvements, prevention of Secondary Progressive MS remains elusive.2
Understanding of the relative efficacy of the newer medications and their long-term effects is growing. However, the wider choice now makes it harder for clinicians, their patients and funding bodies to pick the drug and the timing and weigh the cost in terms of both side-effects and price point. Unfortunately, many MS sufferers have not had the benefit of receiving these treatments early in the disease and their mortality is increased (all cause standardised mortality ratio 2.80).3 The figure has remained stagnant over 50 years, suggesting the increased life expectancy in the general population is also seen in MS.
Despite the lack of a robust model for predicting disability progression, clinical markers are increasingly used in combination with MRI and cerebrospinal fluid markers to improve the information given to patients.4
Clinical factors and MRI changes that predict disability progression include:
While several challenges remain, MS management is undergoing a quiet “revolution”, especially since 2009.5 For example, studies show the effectiveness of new drugs with anti-inflammatory properties, with the goal of preventing tissue injury early in the life of the disease. In the future, therapies will be tailored to individuals, attacking the disease "at many levels and using varied strategies".6
Until clear benefits in mortality are demonstrated rates for life insurance are unlikely to be revised. It’s also too early for any improvements in outcomes to prompt insurers to consider rates for disability products. While in the future, more predictably effective therapies for all forms of MS may make it easier to consider this cover, for now continued caution is needed due to the varied nature of this condition and the difficulty in identifying the type at underwriting stage.
- Hempel, S. et al (2017) A systematic review of modifiable risk factors in the progression of multiple sclerosis. Multiple Sclerosis Journal 1-9.
- Manouchehrinia, A. et al (2015) J Neurol Neurosurg Psychiatry 2015;0:1-8.
- Gajofatto, A. et al (2013) Clinical, MRI and CSF markers of disability progression in multiple sclerosis. Disease Markers. 35. 687-699.
- Ransohoff, RM. et al (2015) Multiple sclerosis - a quiet revolution. Nature Reviews Neurology. 11. 134-142.
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