New Clinical Practice Guidelines, November 2017

John Anello; Brian Feinberg; Richard Lindsey; Cristina Wojdylo; Olivia Wong, DO; Yonah Korngold; John Heinegg; Sam Shlomo Spaeth

Disclosures

November 08, 2017

In This Article

Multiple Sclerosis

European Committee for Research and Treatment of Multiple Sclerosis and the European Academy of Neurology

The entire spectrum of disease-modifying drugs should be prescribed only in centers with adequate infrastructure to provide proper monitoring of patients, comprehensive assessment, detection of side effects, and capacity to address them properly.

Offer interferon or glatiramer acetate to patients with clinically isolated syndrome and abnormal MRI findings with lesions suggesting MS who do not fulfill full criteria for MS.

Offer early treatment with disease-modifying drugs in patients with active relapsing-remitting MS (RRMS), as defined by clinical relapses and/or MRI activity (active lesions; contrast-enhancing lesions; new or unequivocally enlarging T2 lesions assessed at least annually).

For active RRMS, choosing among the wide range of available drugs from the modestly effective to the highly effective will depend on patient characteristics and comorbidity, disease severity, drug safety profile, and accessibility of the drug.

Consider treatment with interferon in patients with active secondary progressive MS (SPMS), taking into account, in discussion with the patient, the dubious efficacy, as well as safety and tolerability profile.

Consider treatment with mitoxantrone in patients with active SPMS, taking into account the efficacy and specifically the safety and tolerability profile of this agent.

Consider ocrelizumab for patients with primary progressive MS.

Consider combining MRI with clinical measures when evaluating disease evolution in treated patients.

When monitoring treatment response in patients treated with disease-modifying drugs, perform standardized reference brain MRI within 6 months of treatment onset and compare the results with those of further brain MRI, typically performed 12 months after starting treatment. Adjust the timing of both MRIs, taking into account the drug's mechanism and speed of action and disease activity, including clinical and MRI measures.

When monitoring treatment response in patients treated with disease-modifying drugs, the measurement of new or unequivocally enlarging T2 lesions is the preferred MRI method, supplemented by gadolinium-enhancing lesions for monitoring treatment response. Evaluation of these parameters requires high-quality standardized MRI scans and interpretation by highly qualified readers with experience in MS.

When monitoring treatment safety in patients treated with disease-modifying drugs, perform standard reference MRI every year in patients at low risk for progressive multifocal leukoencephalopathy (PML), and more frequently (3 to 6 months) in patients at high risk for PML (JC virus positivity, natalizumab treatment duration over 18 months) and in patients at high risk for PML who switch drugs at the time the current treatment is discontinued and the new treatment is started.

Offer a more efficacious drug to patients treated with interferon or glatiramer acetate who show evidence of disease activity, assessed as recommended above.

Advise all women of childbearing potential that disease-modifying drugs are not licensed during pregnancy, except glatiramer acetate.

For women planning a pregnancy, if there is a high risk for disease reactivation, consider using interferon or glatiramer acetate until pregnancy is confirmed. In some very specific (active) cases, continuing this treatment during pregnancy could also be considered.

For women with persistent high disease activity, it would generally be advised to delay pregnancy. For those who still decide to become pregnant or have an unplanned pregnancy, treatment with natalizumab throughout pregnancy may be considered after full discussion of potential implications; or treatment with alemtuzumab could be an alternative for planned pregnancy in very active cases, provided that a 4-month interval is strictly observed from the latest infusion until conception.

Reference

  • Hughes S. European MS treatment guidelines released. Medscape Conference News. WebMD Inc. October 27, 2017. 

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