New European Guidelines for MS

Guidelines on the use of disease-modifying therapies in multiple sclerosis have been released jointly by the European Committee for Research and Treatment of Multiple Sclerosis ECTRIMS and the European Academy of Neurology EAN October 27, 2017, at the 7th Joint ECTRIMS Americas Committee for Research and Treatment of Multiple Sclerosis ACTRIMS 2017 meeting in Paris.

The treatment of multiple sclerosis (MS) has changed radically with the addition of a number of new medicines over the years necessitating the need of new treatment recommendations.The AAN guidelines update the previous 2002 statement and target nonexpert general neurologists rather than MS specialists.

European Guideline Highlights :

• The 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. (Consensus statement)


• 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. (Consensus statement)


• Always consult the summary of product characteristics for dosage, special warnings, and precautions for use, contraindications, and monitoring of side effects and potential harms. (Consensus statement).


• 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. (Consensus statement).


• 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. (Consensus statement).


• 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. (Consensus statement).


• 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. (Consensus statement)


• When deciding on which drug to switch to, in consultation with the patient, consider patient characteristics and comorbidities, drug safety profile, and disease severity/activity. (Consensus statement)


• When treatment with a highly efficacious drug is stopped, whether due to inefficacy or safety, consider starting another highly efficacious drug. When starting the new drug, take into account disease activity (clinical and MRI; the greater the disease activity, the greater the urgency to start new treatment), the half-life and biological activity of the previous drug, and the potential for resumed disease activity or even rebound (particularly with natalizumab). (Consensus statement)


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


• Offer interferon or glatiramer acetate to patients with CIS and abnormal MRI findings with lesions suggesting MS who do not fulfill full criteria for MS. (Strong)


• 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). (Strong).


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


• 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. (Weak)


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


• Consider combining MRI with clinical measures when evaluating disease evolution in treated patients. (Weak )


• In treatment decisions, consider the possibility of resumed disease activity or even rebound when stopping treatment, particularly with natalizumab. (Weak).


• Consider continuing a disease-modifying drug if the patient is stable (clinically and on MRI) and shows no safety or tolerability issues.


• 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. (Weak)


• For women with persistently 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. (Weak)

The final version of Guidelines shall be published in European Journal of Neurology.Meanwhile, American guidelines for MS are awaited which may not be that specific, specialists feel.