Treatment Optimization in MS: Canadian MS Working Group Updated Recommendations

Abstract

The Canadian Multiple Sclerosis Working Group (CMSWG) developed practical recommendations in 2004 to assist clinicians in optimizing the use of disease-modifying therapies (DMT) in patients with relapsing multiple sclerosis. The CMSWG convened to review how disease activity is assessed, propose a more current approach for assessing suboptimal response, and to suggest a scheme for switching or escalating treatment. Practical criteria for relapses, Expanded Disability Status Scale (EDSS) progression and MRI were developed to classify the clinical level of concern as Low, Medium and High. The group concluded that a change in treatment may be considered in any RRMS patient if there is a high level of concern in any one domain (relapses, progression or MRI), a medium level of concern in any two domains, or a low level of concern in all three domains. These recommendations for assessing treatment response should assist clinicians in making more rational choices in their management of relapsing MS patients.

MAGNIMS consensus guidelines on the use of MRI in multiple sclerosis—establishing disease prognosis and monitoring patients

“…Several studies have attempted to define criteria and strategies for the early identification of suboptimal response in individual patients via a combination of clin ical and MRI measures during the first 6-12 months after treatment initiation. 67,[78][79][80][81][82] These criteria are partially or completely based on the detection of disease activity in follow up brain MRI scans, defined as new gadolinium enhancing lesions or new and/or enlarging T2 lesions compared with baseline scans.…”

“…Furthermore, some drugs, such as glatiramer acetate, require up to 6 months to become effective. 81,83 Therefore, the presence of new T2 lesions on a 6-12 month follow up scan does not neces sarily reflect suboptimal response; it could simply be ongoing disease activity during the period before treat ment was initiated or before the drug became effective. 84,85 Accordingly, some experts have proposed that the refer ence scan should be performed 6 months after-rather than before-treatment initiation.…”

“…84,85 Accordingly, some experts have proposed that the refer ence scan should be performed 6 months after-rather than before-treatment initiation. 81,86 Follow-up measurement Gadolinium enhancing lesions are typically easier to identify than new and/or enlarged T2 lesions, and the process is also less dependent on technical factors such as scan repositioning. Furthermore, some new T2 lesions can only be visually detected after being identi fied as new gadolinium enhancing lesions, owing to their small size or their location in areas with confluent lesions.…”

MRI in the Diagnosis and Monitoring of Multiple Sclerosis: An Update

“…Thus, repeated MRI investigations are an established tool to detect and monitor subclinical disease activity. The most commonly used and recommended parameters that can be used in everyday practice are the detection of gadolinium (Gd)-enhancing T1 lesions and the detection of active (new or enlarging) T2 lesions [27,28]. Although hypointense T1 lesions (black holes) correlate better with disability, this parameter reflects rather the persisting damage and not acute inflammatory disease activity.…”

Use of Natalizumab in Patients with Multiple Sclerosis: 2015 Update

“…14 The degree to which relapse rate and disability progression are unacceptable is a judgment call to be made on a case-by-case basis by the treating neurologist. 15 Importantly, use of natalizumab should occur when there is evidence of disease activity despite the use of a first-line agent. In general, patients with a lower EDSS score at the beginning of therapy are more likely to benefit from natalizumab.…”