The American Academy of Neurology (AAN) has released a new practice guideline intended to help clinicians make decisions about disease-modifying therapies for people with multiple sclerosis, or MS.
The new guideline updates a previous set of treatment recommendations released by the AAN in 2002. Since that time, many new medications have been approved for MS, and accumulating evidence has pointed to the benefits of beginning treatment as soon after diagnosis as possible.
“Part of the reason for the new guideline is simply to make sure that clinicians understand that they need to give patients the opportunity to discuss and consider all the medications that might be relevant for them,” says Anne Cross, MD, a Washington University neurologist at Barnes-Jewish Hospital.
The guideline recognizes the complexity involved in making decisions about MS treatment and urges clinicians to thoroughly counsel patients about the disease and their treatment options. It consists of 30 separate recommendations, broken down into three sections:
- Starting disease-modifying therapy
- Switching therapies
- Stopping therapy
The guideline also summarizes the evidence related to various available therapies, including their effectiveness and their potential risks.
“Much complexity has come into the MS field in the last 10 years or so, with many new medications associated with varying types of risk and varying ways of monitoring,” Cross says. “The new guideline helps clinicians — particularly those who have patients with MS but are not MS specialists — consider all the different medications and different scenarios to make fully informed treatment decisions.”
Notably, the guideline recommends that clinicians offer ocrelizumab, which was approved by the Food and Drug Administration in early 2017, to patients with primary progressive MS unless the risks outweigh the benefits. However, Cross points out that the guideline does not mention use of ocrelizumab for highly active MS, “even though most MS experts in the country would consider it because it is highly effective.”
In addition, the guideline includes a recommendation that clinicians prescribe, or at least offer, disease-modifying therapy to people who have had a single clinical demyelinating event — an episode involving damage to neurons’ protective coating — and at least two brain lesions detected by magnetic resonance imagining (MRI) suggesting a high risk for MS.
The new guideline’s biggest takeaway may be that people with MS have many options.
“A patient should perhaps expect a few more visits with the neurologist after diagnosis to talk about the disease and all the therapies associated with it,” Cross says. “It can also be helpful for patients to understand that because there are so many medications available, they shouldn’t be suffering from lots of side effects. If they are, they should consider switching medications.”
Separately, an international panel of experts recently revised the McDonald Criteria for the Diagnosis of Multiple Sclerosis for the first time since 2010. The revised criteria are expected to speed the diagnosis process and decrease the likelihood of misdiagnosis, which Cross says often results from incorrect application of the McDonald Criteria.
She emphasizes that the criteria are intended to be applied to people with typical demyelinating syndromes — rather than just any neurological problem — and that the revised version more clearly explains those syndromes.
Key changes to the diagnostic criteria involve:
- The site of lesions. Specifically, cortical lesions, or those in the cerebral cortex, seen with MRI, can be used in making an MS diagnosis.
- The types of lesions. Symptomatic lesions — in addition to asymptomatic ones — that are contrast-enhancing on MRI can be considered in the diagnosis process.
- Oligoclonal bands. Positive findings of oligoclonal bands, which are a type of protein, in the cerebrospinal fluid can allow a diagnosis of MS in patients with a typical clinically isolated syndrome and either clinical or MRI evidence of MS.
“Though the new criteria won’t get rid of misdiagnoses, they will certainly be helpful,” Cross says.