What is the recommended treatment for men diagnosed with multiple sclerosis (MS)?

Treatment Recommendations for Men with Multiple Sclerosis

For men diagnosed with multiple sclerosis (MS), disease-modifying therapies (DMTs) should be initiated early in the disease course, with high-efficacy DMTs recommended as first-line treatment for those with markers of aggressive disease, while autologous hematopoietic stem cell transplantation (AHSCT) should be considered for treatment-refractory cases. 1, 2

Initial Treatment Approach

• Treatment selection should be based on MS subtype (relapsing-remitting, secondary progressive, or primary progressive), disease activity, and patient characteristics 1
• High-efficacy DMTs (including monoclonal antibodies like alemtuzumab, natalizumab, ocrelizumab, and ofatumumab) are more effective when initiated early in the disease course 1, 2
• For relapsing forms of MS (including clinically isolated syndrome, relapsing-remitting disease, and active secondary progressive disease), FDA-approved treatments include interferon beta-1a, which can be administered intramuscularly 3
• Current evidence favors early escalation and induction treatment strategies over traditional stepped approaches 1

Treatment for Aggressive Disease

• For patients with markers of aggressive disease (frequent relapses, incomplete recovery, high frequency of new MRI lesions, rapid disability onset), high-efficacy DMTs should be considered as first-line treatment 1
• In patients with highly active MS that fails to respond to high-efficacy DMTs, AHSCT should be considered as an appropriate escalation therapy 4
• AHSCT is most suitable for patients who are:
  • Younger than 45 years of age 4
  • Have disease duration less than 10 years 4
  • Have high focal inflammation 4
  • Have EDSS score less than 4.0 4
  • Have relapsing-remitting MS 4

Treatment for Progressive Forms

• For primary progressive MS, ocrelizumab is indicated as a specific treatment, though its efficacy is primarily limited to slowing disability progression 1
• AHSCT should only be considered for young (<45 years) individuals with early progressive MS who have a short disease duration and documented clinical and radiological evidence of inflammatory disease 4
• AHSCT is not recommended for progressive MS without detectable inflammatory lesion activity due to lack of evidence 4
• AHSCT is not recommended for long-standing, advanced forms of MS with severe disability due to high risk and low benefit 4

Monitoring and Treatment Adjustment

• MRI follow-up should be conducted within 3-12 months depending on disease characteristics and treatment 5
• For patients with incomplete recovery after relapses, evaluate for DMT adjustment 5
• In cases of treatment-refractory disease with frequent relapses, AHSCT may be considered in appropriate candidates 5

Special Considerations for AHSCT

• AHSCT should only be considered as first-line therapy for individuals with rapidly evolving, severe MS with poor prognosis, and should be offered as part of a clinical trial or observational study 4
• Assessment for AHSCT requires detailed neurological evaluation, disease history, disability status, and MRI examination 4
• Patients require thorough pre-transplant assessment to confirm eligibility and screen for contraindications 4
• The impact of previous DMTs on safety should be considered, as carryover effects can complicate mobilization, conditioning, and immune reconstitution 4

Common Pitfalls to Avoid

• Delaying treatment initiation can lead to irreversible neurological damage and disability progression 6, 7
• Poor adherence to injectable therapies is common and may reduce treatment effectiveness; consider oral or less frequent administration options when appropriate 8, 9
• Pseudoatrophy effect can cause excessive decrease in brain volume within the first 6-12 months of treatment due to resolution of inflammation, which should not be mistaken for disease progression 2
• Inappropriate washout periods between different DMTs can lead to complications from carryover effects 2

Age-Specific Considerations

• Patients under 45 years with disease duration less than 10 years are optimal candidates for more intensive treatments, including AHSCT if indicated 1
• For patients over 55 years with disease duration greater than 20 years and absence of focal inflammation, AHSCT is not recommended and more conservative approaches may be required 1
• In older patients with stable disease, discontinuation of treatment may be considered as the benefits of continuing immunosuppressive therapy may be outweighed by increased risk of infections and other adverse effects 1