What are the treatment options for managing Multiple Sclerosis (MS) symptoms?

Treatment Options for Managing Multiple Sclerosis (MS) Symptoms

Disease-modifying therapies (DMTs) are the cornerstone of MS treatment, with options ranging from injectable interferons to high-efficacy monoclonal antibodies, while autologous hematopoietic stem cell transplantation (AHSCT) should be considered for patients with highly active disease that fails to respond to high-efficacy DMTs. 1, 2

First-Line Disease-Modifying Therapies

• Injectable therapies including interferon beta-1b and interferon beta-1a reduce relapse rates and delay disability progression in relapsing forms of MS 3, 4
• Oral medications such as fingolimod are indicated for relapsing forms of MS, including clinically isolated syndrome, relapsing-remitting disease, and active secondary progressive disease 5
• DMTs can reduce annual relapse rates by 29-68% compared to placebo or active comparators 1
• Early initiation of DMTs has been shown to improve long-term outcomes and delay conversion to clinically definite MS in patients with clinically isolated syndrome 6

Treatment Escalation for Active Disease

• For patients with highly active disease despite first-line therapy, escalation to high-efficacy DMTs should be considered 2
• High-efficacy DMTs typically include monoclonal antibodies such as alemtuzumab, natalizumab, ocrelizumab, and ofatumumab 7
• Early escalation to high-efficacy therapy is more effective than stepped care approaches, particularly for patients showing signs of aggressive disease 7
• Markers of aggressive disease include frequent relapses, incomplete recovery from relapses, high frequency of new MRI lesions, and rapid onset of disability 7

Autologous Hematopoietic Stem Cell Transplantation (AHSCT)

• AHSCT should be considered for patients with highly active MS in whom high-efficacy DMT has failed 7

• Optimal candidates for AHSCT include: 7

  • Patients under 45 years of age
  • Disease duration less than 10 years
  • High focal inflammation on MRI
  • EDSS score less than 4.0
  • Absence of cognitive impairment
  • Relapsing-remitting MS (rather than progressive forms)

• AHSCT is not recommended for patients with: 7

  • Age over 55 years
  • Disease duration greater than 20 years
  • Absence of inflammatory activity
  • EDSS score greater than 6.0
  • Major cognitive impairment
  • Secondary progressive MS without evidence of inflammatory activity

Management of MS Flares/Relapses

• Corticosteroids are the primary treatment for acute MS flares 2
• MRI follow-up should be conducted within 3-12 months after a flare, including T2-weighted, FLAIR, and T1-weighted sequences with gadolinium enhancement 2
• For patients with incomplete recovery after initial corticosteroid treatment, evaluation for DMT adjustment is recommended 2
• Rehabilitation strategies should be implemented as soon as possible after the acute phase of treatment 2

Special Considerations for Progressive MS

• Ocrelizumab is approved for primary progressive MS 1
• AHSCT can be considered for young (<45 years) individuals with early progressive MS who have a short disease duration and well-documented clinical and radiological evidence of inflammatory disease 7
• AHSCT is not recommended for progressive MS without detectable inflammatory lesion activity due to lack of evidence 7
• For patients with long-standing, advanced forms of MS with severe disability, AHSCT is not recommended due to high risk and low or no benefit 7

Practical Approach to MS Treatment

1. Begin with appropriate DMT based on disease activity and patient factors 1, 8
2. Monitor disease activity through clinical evaluation and MRI imaging 2
3. For patients with breakthrough disease activity despite DMT, consider escalation to higher-efficacy therapy 7
4. Refer patients with highly active, treatment-refractory MS as early as possible for consideration of AHSCT 7
5. For patients with markers of aggressive disease, AHSCT can be considered after failure of a single high-efficacy DMT 7

Pitfalls and Caveats

• Delayed initiation of treatment and poor adherence to DMTs are associated with worse outcomes 6
• Progressive MS remains an area with limited disease-modifying treatment options 9
• AHSCT carries higher acute risks than many approved DMTs, so patient selection is critical 7
• The long-term benefits of many DMTs remain unclear despite their efficacy in reducing relapse risk 8