Hospitalist Clinical Practice Guidelines: 2018 Midyear Review

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


July 03, 2018

In This Article

Multiple Sclerosis

American Academy of Neurology

In people with MS, comorbid disease, such as depression, anxiety, and vascular risk factors, and adverse health behaviors (eg, physical inactivity, smoking) are associated with worse outcomes. Addressing depression before initiating disease-modifying therapy (DMT) may improve decision-making and adherence to DMT. Concomitant medications may have important interactions with DMTs.

After discussing the risks and benefits, clinicians should prescribe DMT to people with a single clinical demyelinating event and 2 or more brain lesions characteristic of MS who decide they want this therapy.

Clinicians may recommend serial imaging at least annually for the first 5 years and close follow-up rather than initiating DMT in people with clinically isolated syndromes (CIS) or relapsing forms of MS who are not on DMT, have not had relapses in the preceding 2 years, and do not have active new MRI lesion activity on recent imaging.

Clinicians should follow up either annually or according to medication-specific risk evaluation and mitigation strategies (REMS) in people with MS on DMTs.

Chemotherapy, such as cyclophosphamide, may affect male fertility. With teriflunomide treatment, there may be a risk of teratogenicity from male sperm, which could last for 2 years after treatment cessation if the patient is not treated with chelation therapy. Clinicians should counsel men with MS on their reproductive plans regarding treatment implications before initiating treatment with teriflunomide or cyclophosphamide.

Because of the high frequency of severe adverse effects (AEs), clinicians should not prescribe mitoxantrone to people with MS unless the potential therapeutic benefits greatly outweigh the risks.

Clinicians should prescribe alemtuzumab, fingolimod, or natalizumab for people with highly active MS.

Clinicians may recommend azathioprine or cladribine for people with relapsing forms of MS who do not have access to approved DMTs.

Clinicians may initiate natalizumab treatment in people with MS with positive anti-JCV antibody indexes above 0.9 only when there is a reasonable chance of benefit compared with the low but serious risk of PML.

Clinicians should offer ocrelizumab to people with primary progressive MS (PPMS) who are likely to benefit from this therapy unless there are risks of treatment that outweigh the benefits.

Clinicians should discuss a change to noninjectable or less frequently injectable DMTs in people with MS who report intolerable discomfort with the injections or in those who report injection fatigue on injectable DMTs.

Persistent laboratory abnormalities, such as elevated liver enzymes and decreased white blood cell counts, may prompt a discussion about switching DMT. Clinicians should monitor laboratory abnormalities found on requisite laboratory surveillance (as outlined in the medication's package insert) in people with MS who are using a DMT.

Clinicians should counsel people with MS considering natalizumab, fingolimod, rituximab, ocrelizumab, and dimethyl fumarate about the progressive multifocal leukoencephalopathy (PML) risk associated with these agents.

Clinicians should discuss switching to a DMT with a lower PML risk with people with MS taking natalizumab who are or become JCV antibody–positive, especially with an index of above 0.9 while on therapy.

Clinicians should check for natalizumab antibodies in people with MS who have infusion reactions before subsequent infusions or in people with MS who experience breakthrough disease activity with natalizumab use. Clinicians should switch DMTs in people with MS who have persistent natalizumab antibodies.

Physicians must counsel people with MS considering natalizumab discontinuation that there is an increased risk of MS relapse or MRI-detected disease activity within 6 months of discontinuation.

Physicians and people with MS choosing to switch from natalizumab to fingolimod should initiate treatment within 8–12 weeks after natalizumab discontinuation (for reasons other than pregnancy or pregnancy planning) to diminish the return of disease activity.

Clinicians should counsel women to stop their DMT before conception for planned pregnancies unless the risk of MS activity during pregnancy outweighs the risk associated with the specific DMT during pregnancy.

Clinicians should not initiate DMTs during pregnancy unless the risk of MS activity during pregnancy outweighs the risk associated with the specific DMT during pregnancy.


  • Jeffrey S. New AAN Guidelines Advocate Early MS Treatment. Medscape News. WebMD Inc. April 23, 2018.

  • Rae-Grant A, Day GS, Marrie RA, et al. Practice guideline recommendations summary: Disease-modifying therapies for adults with multiple sclerosis. Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology. Neurology. 2018 Apr 24;90(17):777-788.


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