What is the management approach for a patient with radiologically isolated syndrome (RIS) who does not meet the 2017 McDonald criteria for relapsing-remitting multiple sclerosis (MS)?

From the Guidelines

The management approach for a patient with radiologically isolated syndrome (RIS) who does not meet the 2017 McDonald criteria for relapsing-remitting multiple sclerosis (MS) primarily involves close monitoring with a follow-up brain scan 3–6 months after the initial MRI, as recommended by the Magnims consensus guidelines 1. The goal of this approach is to detect any potential disease activity or progression while avoiding unnecessary treatment.

• Key components of the management plan include:
  • Clinical evaluations every 6-12 months with a neurologist specializing in MS to detect subtle changes
  • Annual MRI surveillance for the first 2-5 years, then less frequently if stable
  • Additional testing, such as visual evoked potentials and optical coherence tomography, to detect subclinical involvement
• Disease-modifying therapies are not routinely recommended for RIS, but certain high-risk patients, such as those with spinal cord lesions, younger age, or high lesion load, may benefit from earlier intervention with medications like dimethyl fumarate, teriflunomide, or interferons after thorough discussion of risks and benefits, as suggested by the guidelines 1.
• Patient education about MS symptoms is essential to ensure prompt reporting of new neurological symptoms, allowing for timely intervention if the disease progresses. This conservative approach is justified because approximately 30-45% of RIS patients will develop clinically definite MS within 5 years, while others may remain stable indefinitely, making careful monitoring the most appropriate strategy to avoid unnecessary treatment while ensuring timely intervention if the disease progresses, in line with the recommendations from the Magnims consensus guidelines 1.

From the Research

Management Approach for Radiologically Isolated Syndrome (RIS)

The management approach for a patient with radiologically isolated syndrome (RIS) who does not meet the 2017 McDonald criteria for relapsing-remitting multiple sclerosis (MS) involves careful monitoring and consideration of disease-modifying therapies (DMTs).

• Key considerations include:
  • The patient's risk factors for conversion to clinically definite central nervous system (CNS) demyelinating disease, such as spinal cord lesions and gadolinium-enhancing lesions 2
  • The presence of new demyelinating lesions on longitudinal brain imaging, which may indicate disease activity 2
  • The potential benefits and risks of early treatment with DMTs, which may mitigate the impact of recognized risk factors on the occurrence of clinically evident disease 2

Disease-Modifying Therapies (DMTs) in RIS

The use of DMTs in RIS patients is a topic of ongoing debate, with some studies suggesting that early treatment may reduce the likelihood of conversion to clinically definite CNS demyelinating disease in high-risk individuals 2, 3.

• Factors to consider when deciding whether to initiate DMTs in RIS patients include:
  • The presence of recognized risk factors for conversion to clinically definite disease, such as age, sex, and spinal cord lesions 4
  • The patient's individual risk profile and the potential benefits and risks of treatment 3, 5
  • The availability of longitudinal clinical data and imaging findings to inform treatment decisions 2, 4

Monitoring and Follow-Up

Regular monitoring and follow-up are essential for RIS patients, regardless of whether they are receiving DMTs.

• Key components of monitoring and follow-up include:
  • Regular clinical assessments to detect any changes in neurological function or symptoms 2, 4
  • Longitudinal brain imaging to monitor disease activity and progression 2, 5
  • Consideration of cognitive impairment and other potential complications of RIS 4