49 msfocusmagazine.org immunosuppressant drug. The tenth case of rituximab-associated PMLwas in a personwith MS on a prolonged course of natalizumab with high titers of JC virus antibody. So, where does this new drug fit in the tool box? It is the only FDA-approved option for PPMS. It will likely be used in people with RRMS who have failed other therapies or are in higher risk groups for PML on Tysabri. It could be used as a first-line therapy in RRMS as well and there will be a large study starting that looks at this group of people. High hemoglobin levels may play role in brain shrinkage According to a new study, hemoglobin leaked from damaged red blood cells may be associated with brain shrinkage in MS. These early-stage findings suggest treatments that lower levels of hemoglobin could slow progression of the disease. If confirmed, they may suggest new avenues of treatment, and more options for patients in the future. Previous research found high amounts of iron deposited around blood vessels in the brain. In the new study, the team from Imperial College London suggests that hemoglobin, which carries iron and oxygen around the body, may cause these high iron levels. Although the mineral is crucial for our bodies to function, it is toxic in high levels – and scientists have suggested this may trigger the death of brain cells in MS. Thrower – Disability from MS occurs largely because of permanent tissue damage in the brain and spinal cord. In 1998, Dr. BruceTrapp and his team showed that MS does more than just damage the myelin around axons. It also damages the axon itself. This axonal damage is irreversible and may lead to the death of the cell (neuron). When axons and neurons die, we see atrophy of the brain and spinal cord. What causes this axonal and cellular death, and how do we prevent it? Research has focused on many avenues for potential therapies, including howourexisting disease-modifying therapies mayhelp prevent atrophyanddisability.We’ve come a long way since the days when no FDA-approved treatments were available, but we have not achieved the goal of preventing all disability and, someday, reversing it. This research by the team at Imperial may shed light on one of the pathways leading to neuronal death in MS. More importantly, can we slow MS progression by decreasing levels? Increased levels of free hemoglobin are seen in other non-MS health conditions, like sickle cell disease and there is research looking at ways of reducing those levels in that condition. Perhaps, these therapies may be looked at in MS as well. Stay tuned. Ocrelizumab is the only FDA-approved option for PPMS.