I am pleased to welcome Associate Professor Dr. Abdulkadir Tunç in this interview, a neurologist who has dedicated his career to understanding and treating multiple sclerosis (MS), including late-onset multiple sclerosis (LOMS). Dr. Tunç is passionate about helping people overcome the challenges of MS and improve their quality of life through personalized care and innovative research.
Dr. Tunç’s continuing education, including his graduation from the renowned International Charcot MS Master’s Program, has given him an in-depth knowledge of the complexities of MS. He heads a neuroimmunology clinic at Sakarya University in Turkey, where he and his team specialize in finding the best treatments for each patient’s individual needs.
Today, he shares insights into the management of LOMS and tips on how patients can live well with it.
Table of Contents
Introduction – Who is Assoc. Prof. Dr. Abdulkadir Tunc?
Assoc. Prof. Dr. Abdulkadir Tunc: Thank you for having me; it’s a pleasure to be here. I am Assoc. Prof. Dr. Abdulkadir Tunç, a neurologist specializing in neuroimmunology, particularly MS and autoimmune neuromuscular diseases. For over 10 years, I have been closely working with MS patients, providing care and contributing to research aimed at improving their quality of life. I am proud to have completed the prestigious International Charcot MS Master program, which deepened my understanding of MS and its management.
Currently, I run neuroimmunology clinics at Sakarya University, where my team and I focus on personalized approaches to treatment. Beyond my clinical work, I actively participate in our national neurology study group and regularly attend international congresses to stay updated on the latest innovations in the field. On a personal note, I’m married and a father of two wonderful children. When I’m not working, I find joy in playing court tennis and swimming regularly—activities that help me recharge and maintain balance in my life. I believe that staying active and curious, both professionally and personally, is key to living fully.
Personal motivation for your career choice?
Assoc. Prof. Dr. Abdulkadir Tunc: My motivation to pursue a career in neurology, particularly in the field of neuroimmunology, stems from a deep curiosity about the complexities of the human brain and nervous system. Early in my medical training, I was drawn to how neurological disorders can profoundly impact a person’s life and the lives of their loved ones. This inspired me to focus on conditions like multiple sclerosis, where I felt I could make a tangible difference. What solidified my commitment was meeting MS patients and seeing both the challenges they face and their incredible resilience.
Every patient’s journey is unique, and I find great fulfillment in helping them navigate these challenges while also working on advancing treatments to improve their outcomes. On a personal level, I have always been inspired by the idea that science and empathy go hand in hand. By building strong connections with my patients, I am reminded daily why I chose this path—to not only treat the disease but to understand the person behind it. This combination of science, innovation, and humanity keeps me motivated every day.
Definition and Differences in Onset of LOMS
What is Late-Onset Multiple Sclerosis (LOMS), and how is it defined in terms of age at diagnosis?
Assoc. Prof. Dr. Abdulkadir Tunc: LOMS refers to multiple sclerosis diagnosed at the age of 50 or older. While MS is commonly recognized as a condition affecting young adults, LOMS highlights that this disease doesn’t adhere strictly to age boundaries. In fact, growing awareness and improved diagnostic tools have helped identify LOMS more frequently. This age-specific classification emphasizes the unique challenges and experiences of older adults diagnosed with MS.
How does LOMS differ from early-onset MS in terms of symptoms, progression, and overall impact on daily life?
Assoc. Prof. Dr. Abdulkadir Tunc: LOMS often presents with more motor symptoms like weakness or difficulty walking as the first sign, whereas younger patients might initially notice vision or sensory changes. The progression of LOMS tends to be faster, with a higher likelihood of developing a progressive disease course, such as primary progressive MS (PPMS) or secondary progressive MS (SPMS).
This is likely due to factors like aging and immune system changes, which reduce the body’s ability to repair nerve damage. In daily life, older adults may face greater challenges in managing MS due to comorbidities like hypertension or diabetes. These can complicate treatment and lead to delays in diagnosis. Additionally, physical disability, measured by the Expanded Disability Status Scale (EDSS), tends to progress more rapidly in LOMS patients, affecting mobility and independence.
Are there any specific factors that contribute to a later onset of MS, or is it typically a matter of delayed diagnosis?
Assoc. Prof. Dr. Abdulkadir Tunc: Several factors contribute to the later onset of MS. Aging-related changes in the immune system, known as immunosenescence, may play a role in triggering the disease later in life. Comorbidities, such as vascular or metabolic conditions, may also increase the risk. However, delayed diagnosis is common due to overlapping symptoms with other age-related conditions, like stroke or arthritis, making MS harder to recognize initially. Moreover, older patients are less likely to participate in clinical trials, which contributes to uncertainties in recognizing and treating LOMS effectively. Despite these challenges, timely diagnosis and appropriate treatment remain critical to improving outcomes for LOMS patients.
Immunotherapies and Treatment Decisions
Are certain immunotherapies more or less suitable for LOMS patients due to the aging immune system and risk of side effects?
Assoc. Prof. Dr. Abdulkadir Tunc: Absolutely. The treatment of LOMS requires a personalized approach that considers the unique challenges of the aging immune system, as well as the patient’s overall health, comorbidities, and the characteristics of their MS. While injectable therapies, like interferons or glatiramer acetate, have historically been considered safe, they are not commonly used as a first-line option for LOMS due to for example tolerability issues.
Instead, recent trends favor oral therapies, such as dimethyl fumarate and teriflunomide, as initial treatment choices. These medications are generally well-tolerated and convenient for patients, making them a suitable starting point in many cases. For patients with aggressive disease or signs of progression, anti cd 20 agents like ocrelizumab, ofatumumab, have become a preferred options. Its effectiveness in controlling both relapses and disability progression makes it a valuable choice, especially in cases with poor prognostic markers like multiple spinal cord lesions, high lesion burden, or evidence of brain or spinal atrophy.
Additional factors influencing therapy selection include gender, smoking status, OCB positivity, elevated IgG index, and recovery after initial pulse steroid treatment. However, therapies like alemtuzumab and natalizumab, while effective, require careful management of risks, including infection and other immune-related side effects. These treatments may still be considered for select patients where the potential benefits outweigh the risks, but they demand vigilant monitoring. In summary, the choice of immunotherapy in LOMS is highly individualized, balancing the patient’s clinical profile, disease activity, and lifestyle needs to ensure both safety and effectiveness.
Repair and Recovery Mechanisms
How do the body’s natural repair mechanisms, like remyelination, differ in older patients with MS compared to younger individuals?
Assoc. Prof. Dr. Abdulkadir Tunc: The body’s ability to repair myelin, the protective coating around nerve fibers damaged in MS, decreases with age. In younger individuals, cells called oligodendrocytes are more active and efficient at producing new myelin, a process known as remyelination. This helps limit damage and supports nerve function even after MS-related attacks.
In older patients, however, this natural repair process becomes less effective. Several factors contribute to this, including the aging of oligodendrocyte precursor cells (OPCs), which are responsible for creating new myelin but become less responsive and efficient at repairing damage as we age. Chronic inflammation in MS can also create an environment that hinders remyelination, a problem that is more pronounced in older individuals due to an imbalanced immune system, a process known as immunosenescence.
Additionally, aging tissues, including the brain and spinal cord, may have fewer growth factors or supportive structures needed for repair, and the accumulation of oxidative damage over time further impairs the body’s ability to repair itself. As a result, older MS patients are more likely to experience progressive forms of the disease, where disability accumulates over time, even without frequent relapses. This underscores the importance of early and effective treatment to slow down disease progression and protect nerve fibers before irreparable damage occurs.
Symptomatic Treatment and Quality of Life
How important is symptomatic treatment for LOMS, and what are the key symptoms that need to be managed?
Assoc. Prof. Dr. Abdulkadir Tunc: Symptomatic treatment is critically important for managing LOMS. While disease-modifying therapies (DMTs) target the underlying progression of MS, symptomatic treatments focus on improving the patient’s quality of life by addressing day-to-day challenges caused by the disease.
In LOMS, symptoms can vary widely but often include mobility challenges such as muscle stiffness, weakness, or spasticity, which can significantly limit mobility and may be alleviated with physical therapy, stretching exercises, and medications like baclofen or tizanidine. Fatigue, one of the most common and debilitating symptoms, can be managed through energy conservation strategies, exercise, and medications like amantadine or modafinil. Neuropathic pain, including burning or tingling sensations, is also prevalent and may be treated with medications like gabapentin, pregabalin, or antidepressants such as amitriptyline.
Bladder and bowel problems, such as frequent urination or constipation, can impact daily life and may require dietary adjustments, pelvic floor therapy, or specific medications. Cognitive impairment, including memory or focus issues, can be addressed with cognitive training or adaptations to daily routines, while mood changes like depression and anxiety benefit from counseling, support groups, or antidepressant treatments. For LOMS patients, managing comorbidities like diabetes or hypertension is also crucial, as these can exacerbate MS symptoms.
Tailored rehabilitation programs that integrate physical, occupational, and speech therapy further enhance overall function and independence. In summary, symptomatic treatments are not just an add-on but a cornerstone of managing LOMS, enabling patients to maintain independence and improve their quality of life.
What role do physical rehabilitation, cognitive therapy, or other non-drug treatments play in the management of LOMS?
Assoc. Prof. Dr. Abdulkadir Tunc: Non-drug treatments play a vital role in managing LOMS, complementing medications to improve both physical and mental well-being. These therapies address the unique challenges faced by aging MS patients and play a crucial role in improving quality of life. Physical rehabilitation is vital for maintaining mobility, strength, and balance, especially in LOMS, where age-related muscle weakness or stiffness can worsen mobility issues.
Targeted exercises improve flexibility, reduce spasticity, strengthen muscles for daily activities, and enhance balance to minimize fall risks, while assistive devices like canes or braces can improve safety and independence. Cognitive therapy addresses challenges such as memory loss or concentration difficulties through strategies like using memory aids, practicing exercises to enhance attention and decision-making, and building resilience to reduce anxiety about cognitive decline. Regular mental stimulation through activities like puzzles, reading, or learning new skills is also beneficial.
Occupational therapy focuses on adapting the patient’s environment and routines by modifying home layouts for accessibility, suggesting tools like grab bars or ergonomic utensils, and teaching energy conservation techniques to manage fatigue. Mind-body therapies, such as yoga, tai chi, and mindfulness meditation, help reduce stress, improve flexibility, and enhance well-being, particularly for managing fatigue and mood changes. Social and emotional support is essential for combating the isolation often experienced by older MS patients.
Support groups, counseling, and family involvement help alleviate loneliness, depression, and anxiety, while engaging in hobbies or community activities fosters social connections. Nutritional counseling further supports overall health by promoting a balanced diet rich in anti-inflammatory foods and addressing specific concerns like weight management or vitamin deficiencies with the guidance of a dietitian. Together, these therapies form a holistic management plan that addresses both the physical and emotional dimensions of living with LOMS, empowering patients to actively participate in their care and improving their quality of life.
Prognosis and Progression of LOMS
What is the typical prognosis for patients with LOMS compared to those diagnosed at a younger age?
Assoc. Prof. Dr. Abdulkadir Tunc: The prognosis for patients with LOMS often differs from those diagnosed at a younger age. Generally, LOMS patients are more likely to experience a faster accumulation of disability and a higher prevalence of progressive disease forms, such as primary progressive MS (PPMS) or secondary progressive MS (SPMS).
This is partly due to age-related factors, such as reduced capacity for remyelination and other repair mechanisms, as well as comorbid conditions like hypertension or diabetes, which can worsen symptoms and complicate management. However, it’s important to note that with appropriate and timely treatment, many LOMS patients can achieve good control of their symptoms and maintain a high quality of life. Early diagnosis and effective therapies play a critical role in slowing disease progression and preserving function.
Does LOMS tend to progress faster or slower than early-onset MS, and are there any predictors of disease progression in this age group?
Assoc. Prof. Dr. Abdulkadir Tunc: LOMS typically progresses faster than early-onset MS, with a greater likelihood of transitioning to a progressive disease course. This accelerated progression in LOMS can be attributed to the reduced repair capacity of the aging nervous system, which becomes less effective at repairing damage caused by MS, and immune aging, or immunosenescence, where older patients often exhibit a more aggressive inflammatory response that contributes to quicker progression.
Several factors predict faster disease progression in LOMS. Patients with significant spinal cord lesions are more likely to experience rapid disability accumulation. Poor recovery after the initial relapse often signals a more aggressive disease course. Biomarkers such as oligoclonal band (OCB) positivity and a high IgG index in cerebrospinal fluid indicate heightened immune activity and greater disease activity.
Age at diagnosis also plays a critical role, with older age correlating with more rapid progression, and comorbidities such as hypertension, diabetes, or smoking further exacerbating symptoms and increasing disability risk. Despite these challenges, advancements in disease-modifying therapies (DMTs) have significantly improved outcomes for LOMS patients. Medications like ocrelizumab and cladribine are particularly effective in slowing disease progression, especially in cases with aggressive disease activity.
New Developments: BTK Inhibitors
Do you think BTK Inhibitors could be a preferred option for immunotherapy in LOMS?
Assoc. Prof. Dr. Abdulkadir Tunc: BTK inhibitors (Bruton’s tyrosine kinase inhibitors) represent a promising new class of immunotherapy for multiple sclerosis, including LOMS. These medications work by selectively targeting B cells, which play a crucial role in the inflammatory processes of MS. BTK inhibitors offer several advantages that make them an appealing option for LOMS patients. One key benefit is their oral administration, which eliminates the need for injections or infusions, providing greater convenience and improving treatment adherence—particularly important for older patients.
Additionally, BTK inhibitors have a targeted mechanism of action, selectively modulating immune pathways to reduce inflammation without broadly suppressing the immune system, which may help lower the risk of serious infections—a significant concern for aging patients with immunosenescence. Emerging research also highlights their potential neuroprotective effects, suggesting they could slow the progression of neurodegeneration, a common challenge in LOMS. Although still under investigation, BTK inhibitors may become a preferred option for LOMS patients, especially those with active disease or who cannot tolerate other treatments due to side effects or comorbidities.
How do BTK Inhibitors balance effectiveness and tolerability for older patients?
Assoc. Prof. Dr. Abdulkadir Tunc: BTK inhibitors have the potential to balance effectiveness and tolerability for older MS patients, including those with LOMS. These therapies effectively reduce B-cell activity, addressing both the inflammatory and neurodegenerative aspects of MS. Their ability to penetrate the central nervous system (CNS) allows them to directly target inflammation within the brain and spinal cord, which is crucial for slowing disease progression. In terms of tolerability, BTK inhibitors may cause fewer systemic side effects compared to some existing therapies since they do not fully deplete B cells.
As oral medications, they also avoid injection-related reactions or infusion-associated side effects, making them more user-friendly for older patients. Additionally, early studies suggest that BTK inhibitors have a manageable safety profile, even for individuals with comorbidities, although careful monitoring is necessary to detect potential side effects like mild gastrointestinal issues or rare immune-related complications. In summary, BTK inhibitors show great promise in effectively managing LOMS while offering improved tolerability for older populations. If ongoing trials confirm these advantages, they could become a valuable option in the treatment landscape for LOMS.
Quickfire Q&A Session
Complete the sentence: "For me, multiple sclerosis is...."
Assoc. Prof. Dr. Abdulkadir Tunc: For me, multiple sclerosis is not just a disease—it’s a puzzle we are solving every day, unlocking new ways to empower patients and transform lives.
What development would you like to see in the field of multiple sclerosis in the next 5 years?
Assoc. Prof. Dr. Abdulkadir Tunc: I’d love to see breakthroughs in precision medicine for MS—therapies tailored to individual patient profiles, including advanced biomarkers to predict disease activity and progression. I also hope for the widespread implementation of neuroprotective treatments and technologies, like AI-assisted diagnostics, to improve early detection and long-term outcomes.
Farewell
Finally, what message of hope or encouragement would you like to share with individuals living with MS?
Assoc. Prof. Dr. Abdulkadir Tunc: To everyone living with MS, remember that you are not defined by this disease. Each day, we’re making progress in understanding MS and developing new treatments to improve lives. Stay hopeful, stay proactive, and never hesitate to lean on your support network. Together, we’re stronger, and together, we’ll continue moving forward.
How and where can interested people follow your research activities?
Assoc. Prof. Dr. Abdulkadir Tunc: You can follow my research and updates through academic platforms like ResearchGate or LinkedIn, where I share my latest publications and projects. I also collaborate with the MSBase Registry and participate in international MS-focused events, so stay tuned for updates from these communities as well.
See you soon and try to make the best out of your life,
Nele
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