From the Guidelines
Risk factors for aggressive multiple sclerosis (MS) include high lesion load on early MRI scans, specifically three or more active lesions in 1 year, which is associated with a high risk of disability progression 1. These risk factors can be identified through various criteria, including:
- Three or more active lesions in 1 year, which has a sensitivity of 71% and specificity of 71% for disability progression over 3 years 1
- Three or more active lesions plus one or more relapse or ≥1 point confirmed EDSS score increase in 1 year, which has an odds ratio of 3.3–9.8 for relapse rates and/or disability progression over 3 years 1
- Modified Rio Score ≥2 and more than five new T2 lesions plus one, which has a sensitivity of 24% and specificity of 97% for relapse rates and/or disability progression over 4 years 1 Other factors that may contribute to aggressive MS include:
- Incomplete recovery from initial relapses
- High relapse rate in the first 2-5 years
- Specific MRI findings such as multiple gadolinium-enhancing lesions, infratentorial lesions, and spinal cord involvement
- Cerebrospinal fluid showing high levels of neurofilament light chain or the presence of oligoclonal bands
- Genetic factors such as certain HLA types associated with worse outcomes
- Environmental factors like smoking, vitamin D deficiency, and obesity that can exacerbate MS progression It is essential to identify these risk factors early, as patients with aggressive MS may benefit from prompt initiation of high-efficacy disease-modifying therapies, potentially slowing disability progression and improving long-term outcomes.
From the Research
Risk Factors for Aggressive MS
Several factors predict aggressive MS, including:
- Demographic factors
- Relapses
- Symptom characteristics
- MRI activity
- Other biomarkers 2 These factors can be used to select patients for more aggressive therapies.
Identifying Patients with Aggressive MS
It is imperative to recognize aggressive MS to effectively treat it before patients progress 3. Natural history studies and contemporary clinical trials help to identify and profile a subset of patients with relapsing MS who have a much poorer prognosis and for whom conventional treatment tends to fail.
Importance of Early Recognition
Early recognition of aggressive MS is the key to successful implementation of a proposed treatment algorithm 3, 4. Identifying patients who are at risk of aggressive MS as early as possible and implementing an effective treatment strategy can protect patients from irreversible damage and disability.
Treatment Options
Therapies that have shown success in the treatment of aggressive MS include natalizumab, alemtuzumab, fingolimod, and ocrelizumab 2. Additional off-label treatments are available for patients with severe disease. The benefits and side effects of these treatments must be considered when making therapeutic decisions.