Your current location is set to United States. If this is incorrect, please change your location:
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:
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:
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:
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:
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:
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:
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:
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:
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:
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:
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:
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:
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:
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:
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:
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: