Treatment optimization in multiple sclerosis: new recommendations from the Canadian MS working group
The Canadian MS Working Group, which consists of neurologists from the Canadian Network of MS Clinics, has released an updated list of recommendations on the optimal use of disease-modifying therapies (DMTs) for individuals with all types of MS and special populations (pregnant women and pediatric MS). These treatment optimization recommendations (TORs) provide guidance on starting, monitoring, and switching therapies to ensure that people are receiving the most optimum treatment, given their disease course and health status. The 16 recommendations have been summarized below. For additional information, a more in-depth review of each recommendation is included here.
The recently revised 2017 criteria for diagnosing MS allow Canadian neurologists to diagnose individuals earlier and more accurately, which also means earlier treatment with a DMT. It is recommended that individuals diagnosed with relapsing-remitting MS start DMT treatment soon after their diagnosis is confirmed to reduce risk of worsening disability over time. Individuals diagnosed with primary progressive MS (PPMS) may qualify for treatment with the first, and only, DMT approved for PPMS, ocrelizumab. Typically, PPMS patients under the age of 55 and those more recently diagnosed with active disease are more likely to respond to this therapy.
Choosing a DMT should be shared decision-making between an individual and their neurologist. Individuals are encouraged to discuss any thoughts or concerns they may have about DMT choices, weighing the risks and benefits of DMTs as part of this decision-making.
In addition to DMTs, there are many strategies that people with MS and their healthcare team can do to manage their MS. This includes making lifestyle changes such as stopping smoking, maintaining a balanced diet, achieving a healthy weight, exercising, managing mental health and other health conditions (hypertension, diabetes).
Monitoring and Switching or Stopping
At regular intervals, neurologists will monitor an individual’s MS using standard clinical measurements, including the expanded disability status scale (EDSS), timed 25-foot walk, and cognitive function assessments. Monitoring is a key component of MS treatment as it can help determine if the DMT is working, if a switch to a higher-efficacy DMT is required, or if other treatment plans need to be considered. Individuals are encouraged to discuss how often they should be monitored by their treating neurologist.
In addition, a neurologist may repeat an individual’s MRI after starting a therapy to compare with their annual MRI and evaluate treatment response to a DMT. If a follow-up MRI shows three or more new lesions while on a DMT within one year, a change in DMT may be recommended. Conversely, if an individual’s MRI has remained stable (no new lesions) for several years on therapy, an MRI is generally not needed annually for continued monitoring.
Other lab work (blood test, blood pressure test, urine analysis) and updating vaccinations is required prior to starting a DMT, as well as during treatment (for some DMTs) as part of the monitoring recommendations.
Many people with relapsing-remitting MS will eventually transition to secondary progressive MS (SPMS) over time, where they have more gradual progression, fewer or no relapses, and an accumulation of disability. Following the onset of SPMS, it is generally recommended to continue using the current DMT. There is a new therapy approved for “active” SPMS in Canada, siponimod, which was not yet available in Canada at the time of review. Some people with early and “active” SPMS (continued relapses and new MRI lesions) might qualify for siponimod.
Neurologists may discuss stopping treatment with a DMT in people living with MS who are over the age of 60, and have been completely stable (no relapses, no MRI activity) over the previous five years.
Pregnancy and DMTs
Women who are considering pregnancy are encouraged to speak with their neurologist. If a planned pregnancy is possible, it is best to do so when the disease has been stable for some time. Women should be counseled on DMT use as some DMTs are contraindicated during the time of trying to conceive, pregnancy and breastfeeding. It is important to understand the potential risks of a DMT in relation to pregnancy and breastfeeding. Research suggests that breastfeeding may be helpful in controlling disease activity following delivery.
DMT Use in Pediatric MS
While MS is rare in children, it can occur. Risk factors for MS in children include low vitamin D levels, smoking, exposure to second-hand smoke, and obesity. Children who have been diagnosed with MS are recommended to start a DMT. There is one Health Canada approved DMT for pediatric MS, fingolimod, however all DMTs used for adults with MS have been used in pediatric MS and are likely effective in controlling the disease. Children taking a DMT are monitored closely over time to manage side-effects and assess treatment response.
For additional information, a more in-depth review of each recommendation is included here.
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