What are the clinical pearls for Multiple Sclerosis (MS)?

From the Guidelines

Multiple sclerosis (MS) management should prioritize early diagnosis and treatment, with the McDonald criteria and MRI findings being essential for diagnosis, and disease-modifying therapies (DMTs) initiated promptly after diagnosis, as supported by the most recent evidence 1. The clinical pearls for MS include the use of MRI to assess disease activity and monitor treatment response, with regular monitoring every 6-12 months recommended 1. Key considerations in MS diagnosis and management include:

• The McDonald criteria, which include clinical presentation and MRI findings, are essential for diagnosis 1
• DMTs should be initiated promptly after diagnosis, with options including injectable medications, oral medications, and infusion therapies 1
• Acute relapses are typically treated with high-dose corticosteroids, usually methylprednisolone 1000mg IV daily for 3-5 days 1
• Symptom management is equally important, addressing fatigue, spasticity, and neuropathic pain with medications such as amantadine, baclofen, and gabapentin 1
• Patients should be counseled on the importance of vitamin D supplementation, regular exercise, avoiding excessive heat, and maintaining vaccinations (avoiding live vaccines if on certain immunosuppressive DMTs) 1
• MS management requires a multidisciplinary approach involving neurologists, physical therapists, occupational therapists, and mental health professionals to address the complex and varied manifestations of the disease 1 The most recent evidence suggests that brain and spinal cord atrophy measures can be used to predict disease evolution and treatment response, and should be considered in clinical practice 1. Some key points to consider when interpreting MRI scans in MS include:
• Lesions should be confirmed on multiple planes to avoid false positive findings due to artefacts and false negative results 1
• Serial imaging can support the diagnosis of MS, given that MS is characterized by the accrual of lesions over time and in new areas of the CNS 1
• Interpretation of the MRI scans should be performed by trained (neuro)radiologists or clinicians deeply familiar with the features of MS and disorders considered in the differential diagnosis 1

From the FDA Drug Label

The primary endpoint at 2 years was time to onset of sustained increase in disability, defined as an increase of at least 1 point on the EDSS from baseline EDSS ≥ 1.0 that was sustained for 12 weeks, or at least a 1.5 point increase on the EDSS from baseline EDSS=0 that was sustained for 12 weeks. Time to onset of sustained increase in disability was longer in TYSABRI-treated patients than in placebo-treated patients in Studies MS1 (Figure 1) and MS2 The proportion of patients with increased disability and the annualized relapse rate were also lower in TYSABRI-treated patients than in placebo-treated patients in Studies MS1 and MS2 (Table 5 and Table 6).

Clinical Pearls for Multiple Sclerosis (MS):

• TYSABRI can delay the onset of sustained increase in disability and reduce the annualized relapse rate in patients with MS.
• The most common adverse reactions in MS patients treated with TYSABRI include headache, fatigue, arthralgia, urinary tract infection, lower respiratory tract infection, gastroenteritis, vaginitis, depression, pain in extremity, abdominal discomfort, diarrhea, and rash.
• Serious adverse reactions associated with TYSABRI in MS patients include infections, acute hypersensitivity reactions, depression, and cholelithiasis.
• TYSABRI has been associated with an increased risk of Progressive Multifocal Leukoencephalopathy (PML), a rare and serious brain infection.
• Patients treated with TYSABRI should be monitored for signs and symptoms of PML and other adverse reactions.
• The efficacy and safety of TYSABRI in combination with other MS therapies have not been fully evaluated.
• TYSABRI is not recommended for patients with a history of PML or who are immunocompromised.
• Patients should be educated on the potential risks and benefits of TYSABRI and the importance of regular monitoring and follow-up appointments 2, 2, 2.

From the Research

Clinical Pearls for Multiple Sclerosis (MS)

• Early intervention with disease-modifying treatments is crucial to optimize long-term clinical outcomes in MS patients 3
• Interferon beta treatment has been shown to reduce the conversion rate of clinically isolated syndrome (CIS) to clinically definite MS, and may also have a protective effect on cognitive function 3
• New disease-modifying therapies, including oral agents and biologics, have been approved for the treatment of relapsing-remitting MS, offering improved flexibility in managing the disease 4
• Novel biologics, such as monoclonal antibodies and small molecules, have entered the scene, targeting molecules involved in immunopathological processes more specifically 5
• Interferon beta-1a and glatiramer acetate have been studied for their ability to affect specific immunity, with interferon beta-1a showing a statistically significant difference in the change of monocytes after 6 months 6

Management of Invisible Symptoms

• Invisible symptoms, such as fatigue, mood disorders, and cognitive impairments, are highly prevalent in MS patients and can impact the disease course 7
• A comprehensive approach to MS management should include addressing these invisible symptoms through open communication, stigma mitigation, and shared decision-making 7
• Validated screening tools and technological advancements can be incorporated into MS care to regularly monitor invisible symptoms and improve patient quality of life 7