What should be assessed in a multiple sclerosis (MS) patient during a follow-up visit in the outpatient department?

Comprehensive Follow-Up Assessment for Multiple Sclerosis Patients

During follow-up visits for multiple sclerosis patients, clinicians should conduct standardized clinical assessments measuring disability and record relapses in parallel with annual brain MRI to detect disease activity and guide therapeutic interventions that improve long-term outcomes. 1

Clinical Assessment Components

Neurological Examination

• Assess for new or worsening neurological symptoms using standardized disability measures:
  • Expanded Disability Status Scale (EDSS) to quantify disability progression 2
  • Disease Steps assessment for practical evaluation of functional status 3
• Evaluate for:
  • Motor function (weakness, spasticity)
  • Sensory changes (numbness, tingling, paresthesias)
  • Coordination and balance issues
  • Visual disturbances
  • Cognitive changes
  • Bladder/bowel dysfunction
  • Fatigue levels

Relapse Assessment

• Document any new neurological symptoms lasting >24 hours 4
• Record frequency, severity, and recovery from relapses since last visit
• Assess need for relapse treatment (typically intravenous methylprednisolone) 5

Imaging Protocol

MRI Monitoring

• Perform annual brain MRI for routine monitoring of disease activity 1
• Standard MRI protocol should include:
  • T1-weighted images with gadolinium contrast
  • T2-weighted images
  • FLAIR sequences
  • Diffusion-weighted images (DWI) for patients at risk of adverse effects 1
• Use the same MRI system and imaging protocol as baseline scans for consistency 6
• Allow minimum 5-minute delay between gadolinium administration and T1 acquisition 1

Treatment-Specific MRI Monitoring

• For natalizumab-treated patients at high risk of PML (JCV seropositive, treatment duration ≥18 months):
  • Brain MRI every 3-4 months with FLAIR, T2, and diffusion-weighted sequences 6, 1, 7
• For JCV seronegative patients on natalizumab:
  • Annual brain MRI assessment 6, 1
• For patients switching disease-modifying medications:
  • MRI at discontinuation of current treatment
  • MRI after initiating new treatment
  • Enhanced monitoring with MRI every 3-4 months for up to 12 months 6, 1

Laboratory Monitoring

Basic Laboratory Tests

• Complete blood count with differential
• Liver function tests
• Renal function (creatinine)
• Thyroid function tests (especially for patients on certain DMTs) 8

Treatment-Specific Monitoring

• For interferon beta treatments:
  • Monitor for decreased peripheral blood counts
  • Watch for symptoms of thrombotic microangiopathy
  • Assess for signs of autoimmune disorders (thyroid dysfunction, thrombocytopenia) 8
• For alemtuzumab:
  • Regular monitoring of complete blood count
  • Thyroid function tests
  • Vigilance for secondary autoimmunity 1

Disease Activity Assessment

NEDA-3 Criteria Evaluation

• No Evidence of Disease Activity assessment based on:
  1. No new/enlarging T2 lesions on MRI
  2. No gadolinium-enhancing lesions on MRI
  3. No clinical relapses
  4. No confirmed disability progression 1

Treatment Response Evaluation

• Assess effectiveness of current disease-modifying therapy
• Consider treatment modification if:
  • New lesions appear on MRI
  • Clinical relapses occur
  • Disability progression is confirmed
  • Intolerable side effects develop

Symptom Management Assessment

• Evaluate and address:
  • Spasticity
  • Fatigue
  • Pain
  • Depression and anxiety
  • Cognitive dysfunction
  • Bladder and bowel dysfunction
  • Sexual dysfunction

Follow-Up Frequency

• Standard follow-up:
  • Clinical assessment every 3-6 months
  • MRI annually for stable patients 1
• Increased monitoring for:
  • Patients with recent disease activity
  • Those on high-risk medications (e.g., natalizumab in JCV+ patients)
  • Patients who recently switched treatments 6, 1

Common Pitfalls to Avoid

1. Relying solely on clinical symptoms - Subclinical disease activity on MRI often precedes clinical relapses
2. Inconsistent MRI protocols - Use the same scanner and protocol for accurate comparison
3. Overlooking cognitive assessment - Cognitive decline may occur independently of physical disability
4. Neglecting treatment-specific monitoring - Different DMTs require specific safety monitoring protocols
5. Missing pseudoatrophy - Brain volume decrease within first 6-12 months of anti-inflammatory treatment may not indicate true atrophy 1

By following this structured approach to MS follow-up assessment, clinicians can detect disease activity early, optimize treatment decisions, and potentially improve long-term outcomes for patients with multiple sclerosis.