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Multiple Sclerosis Society of Canada

Takeaways from the Canadian MS Working Group 2020 Treatment Optimization Recommendations

This document provides an in-depth review and interpretation of the 16 treatment recommendations. This information may be useful for healthcare practitioners or community neurologists with special interest in the management of MS. To view the published article, please visit the following link.

Recommendation 1: Use of the 2017 McDonald criteria is recommended for the diagnosis of relapsing MS (RMS) and primary progressive MS (PPMS). McDonald criteria should only be applied to patients presenting clinically with events that are considered highly suspicious for central nervous system demyelination, after exclusion of reasonable alternative diagnoses.

Takeaway for people with MS:

  • Canadian neurologists follow the 2017 international criteria for diagnosing MS.
  • People with MS can now be diagnosed earlier and more accurately in the course of their disease (i.e. during or shortly after their first clinical attack).
  • Neurologists may wish to do a lumbar puncture to exclude other diseases and to look for changes in spinal fluid consistent with MS.

Recommendation 2: All RMS patients should be encouraged to start treatment with a disease-modifying therapy (DMT) soon after diagnosis to reduce their risk of disability worsening and to improve long-term outcomes.

Takeaway for people with MS:

  • People with RMS should consider starting treatment with a DMT soon after their diagnosis is confirmed.
  • DMTs have been shown to reduce risk of worsening disability over time.
  • People with MS are encouraged to talk to their neurologist about DMT and which option might be right for them.

Recommendation 3: Risk stratification, based on demographic and clinical factors known to be associated with early disease worsening, should be performed for individual patients at first presentation and on an ongoing basis. This will assist clinicians in developing an appropriate treatment plan in consultation with patients and enable prompt optimization of the regimen as required.

Takeaway for people with MS:

  • The goal of a DMT is to have a person with MS experience ‘minimal’ disease activity over time.
  • MS affects each person differently, so neurologists consider various factors when deciding on a DMT (i.e. frequency of attacks, MRI changes).
  • Neurologists monitor people with MS at regular intervals to see if the DMT is working or if stronger DMTs need to be considered.

Recommendation 4: The treatment plan should consider the patient’s general health status including co-morbidities. Wellness efforts, such as smoking cessation, weight reduction and regular physical activity should be encouraged. Vitamin D supplementation (600-4000 IU/day) may provide some added clinical benefit.

Takeaway for people with MS:

  • There are many strategies that people with MS and their healthcare providers (i.e. family doctors) can and should do to help their MS, including blood pressure control, control of diabetes, stopping smoking, maintaining a balanced diet, losing weight, exercising, and treatment of mood changes.
  • These lifestyle and overall health strategies can help to influence a person’s MS, but should be done in addition to MS-targeted treatment options (i.e. as an add-on to a DMT).
  • Taking vitamin D supplements (600 to 4000 IU/day) may also be helpful for people with MS.

Recommendation 5: Clinicians with experience in treating patients with progressive MS (PMS) should offer ocrelizumab to primary progressive MS (PPMS) patients with active disease (relapses and/or MRI activity) provided the benefits outweigh the risks.

Takeaway for people with MS:

  • People with PPMS may qualify for treatment with a DMT.
  • Ocrelizumab is currently approved in Canada for people with PPMS who are having clinical relapses or MRI activity.
  • Younger patients (under the age of 55), or more recently diagnosed patients with active disease, are more likely to have a better response.

Recommendation 6: The therapeutic response should be evaluated early in RMS patients to determine the benefit of therapy within the first two years after DMT initiation. Treatment response should also be continuously evaluated at regular intervals thereafter. Efficacy assessments should be based on at least two timepoints using clinical and radiological outcomes. It is recommended that treatment be switched in the first two years when there is clear evidence of a suboptimal response.

Takeaway for people with MS:

  • “Breakthrough” relapses on a DMT may prompt your neurologist to talk about other therapy options.
  • Usually, neurologists consider clinical relapses and/or new MRI lesions when evaluating DMT treatment response in people with MS.
  • Currently, there is no agreed-upon standards amongst neurologists on what is an adequate treatment response to a DMT.
  • If people with MS have ongoing relapses and MRI lesions over time, their neurologist might consider a change in therapy.

Recommendation 7: The patient’s level of physical disability should be evaluated at least once a year. Some of the most useful measures in practice are the Expanded Disability Status Scale (EDSS), the Timed 25-foot Walk (T25FW), the 9-Hole Peg Test (9HPT), and the Patient-Determined Disease Steps (PDDS). Changes in disability should be confirmed at six months.

Takeaway for people with MS:

  • There are standard clinical measurements that neurologists use in Canada to help monitor a person’s MS over time, including EDSS, Timed 25-foot walk, and Symbol Digit Modalities Test (SDMT).

Recommendation 8: A re-baseline MRI should be obtained after initiating or changing treatment once the DMT is deemed to be fully effective (Table 3 of published article). Follow-up MRIs should be obtained annually for the first few years of treatment.

Takeaway for people with MS:

  • Neurologists may repeat a person’s MRI after starting a therapy as a new “baseline” to help monitor effectiveness of the DMT over time and use annual MRI to monitor response to a DMT.
  • Talk to your neurologist about the role of follow-up MRIs in monitoring your MS.
  • Most follow-up MRIs are done of the brain, not as much of the spinal cord.

Recommendation 9: New/enlarging T2-weighted MRI lesions while on DMT are correlated with new relapses and clinical disability progression over time. A finding of >3 new/enlarging lesions while on a DMT is considered a suboptimal response, and a change in treatment is recommended (Table 2 of published article).

Takeaway for people with MS:

  • If a follow-up MRI shows three or more new lesions while on a DMT within one year, your neurologist may recommend a change in DMT.
  • Once a person’s MRI has remained stable (no new lesions) for a few years on therapy, an MRI is not needed every year for continued monitoring.

Recommendation 10:  Cognition should be tested regularly and as part of an overall assessment of functional change to detect disease activity, relapse recovery or treatment response. The Symbol Digit Modalities Test (SDMT) is the simplest method for screening for cognitive impairment and for identifying changes in cognition over time. An SDMT should be performed at baseline and every 2-3 years. There is insufficient evidence that changing DMTs will improve cognitive outcomes. Accordingly, treatment optimization based on a change in cognitive function alone is not recommended at this time.

Takeaway for people with MS:

  • People with MS can have troubles with their thinking/cognition that can impact their daily functioning – most commonly in the speed of processing information, making decisions, recalling the right word quickly and in short-term memory.
  • Neurologists should monitor cognition in a person with MS by administering SDMT, which takes less than 5 minutes and has high sensitivity and reliability.

Recommendation 11: Most RMS patients can be expected to require more than one DMT during the treatment course to control their disease and limit worsening disability. Escalation to a higher-efficacy therapy is generally recommended for treated patients who meet a Major criterion (Table 2 of published article). When sequencing therapies, clinicians should recognize that a given therapy may have an impact on future treatment choices. Prior to initiating treatment, the clinician should develop a plan as to how medications might be sequenced so that safety concerns or other factors will not limit subsequent treatment options or delay the initiation of the next DMT.

Takeaway for people with MS:

  • Most people with RMS will be on at least one DMT during the course of their disease.
  • The order of use of DMT might reflect best safety practices for a person with MS, rather than the best effect upon the disease.

Recommendation 12:  Prior to initiating a DMT and throughout the treatment course, clinicians should adhere to a standard screening and monitoring protocol to minimize treatment-associated risks. Screening should include an assessment of contraindications and comorbidities that may influence treatment choice.

Takeaway for people with MS:

  • People with MS may be asked to update their vaccinations and perform lab screening (blood test, blood pressure test, urine analysis) before starting a DMT and while on a DMT.

Recommendation 13:  Ongoing treatment of patients transitioning to secondary progressive MS (SPMS) who still have active inflammatory disease is recommended. Use of siponimod, now approved in Canada, may be considered. Consider stopping treatment in patients with SPMS characterized by progression without inflammatory disease activity, with close monitoring to identify breakthrough inflammatory disease activity.

Takeaway for people with MS:

  • People with RMS may transition to SPMS over their lifetime – where they have more gradual changes in their MS over time, instead of having relapses, and an accumulation of disability.
  • It is generally recommended to continue using the current DMT following the onset of SPMS.
  • If people with MS are over the age of 60, and have been completely stable (no relapses, no MRI activity) over the previous 5 years, their neurologists may talk about considering stopping DMT.

Recommendation 14:  Shared decision-making is important when selecting the optimal treatment for individual patients. The potential benefits of specific DMTs must be weighed against the risk of short- and long-term adverse effects associated with that agent. All patients must be fully informed of the potential risks associated with treatment before a DMT is initiated.

Takeaway for people with MS:

  • People with MS are encouraged to talk to their neurologists about their thoughts and concerns about DMT choices and possible side effects of a DMT.
  • A DMT should be chosen together through shared decision-making.

Recommendation 15: Female MS patients of childbearing age should use a reliable method of contraception. Discontinuation of DMTs is generally recommended prior to conception.

Takeaway for people with MS:

  • If able to plan a pregnancy, pregnancy is most ideally planned for when women with MS have been stable with their disease for a while.
  • Talk to your neurologist when considering pregnancy.
  • Some DMTs should not be used in women with MS if there is a chance they may become unexpectedly pregnant in the near future.
  • Breastfeeding can be helpful in controlling a woman’s MS after delivery.
  • Some DMTs are thought to be safer during breastfeeding than others.

Recommendation 16:  Early treatment of pediatric-onset MS is recommended. All DMTs approved for the adult population have been used in pediatric-onset MS and are likely to be efficacious. Treated children and adolescents with MS should be monitored comprehensively, with standardized monitoring according to the specific DMT.

Takeaway for people with MS:

  • MS can occur in children but is rare.
  • Risk factors for MS in children include low vitamin D levels, smoking, exposure to second-hand smoke and obesity.
  • If a child (below the age of 18) is diagnosed with MS, treatment with a DMT is recommended.
  • All DMTs used for adults with MS, have been used in children with MS and are likely effective in controlling their MS.
  • Once on a DMT, children with MS are monitored closely over time in terms of how they are doing on their DMT, how well their MS is controlled, and what side effects they are experiencing.
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