How should I manage a multiple sclerosis patient at a routine follow‑up, including clinical assessment, contrast‑enhanced MRI, disease‑modifying therapy review, relapse treatment, symptom control, and preventive care?

Management of Multiple Sclerosis at Routine Follow-Up

Perform brain MRI every 6-12 months using T2-weighted and T2-FLAIR sequences without contrast in clinically stable patients, reserving gadolinium-enhanced imaging for unexpected clinical deterioration or when detecting new T2 lesions would change management decisions. 1, 2

Clinical Assessment Framework

Neurological Examination

• Assess for new sensory disturbances, motor weakness, impaired gait, incoordination, optic neuritis, and Lhermitte sign at each visit 3
• Document changes in Expanded Disability Status Scale (EDSS) score, as this correlates with lesion burden and treatment response 1
• Evaluate for brainstem syndromes including internuclear ophthalmoplegia 4

Cognitive Monitoring

• Administer the Symbol Digit Modalities Test (SDMT) every 6 months to detect significant cognitive decline while minimizing practice effects 5
• This frequency aligns with MRI monitoring protocols and allows early detection of disease progression 5

Symptom Assessment

• Screen systematically for bowel and bladder dysfunction, depression, fatigue, movement disorders, and pain using standardized patient questionnaires 3, 6
• These tools enhance detection of treatment-related adverse effects and improve compliance 6

MRI Surveillance Protocol

Standard Follow-Up Imaging

• Conduct brain MRI at minimum annually, with frequency increased to every 3-6 months for high-risk patients or those with active disease 1, 2
• Use the same MRI scanner and identical protocols as baseline: T2-weighted, T2-FLAIR, and proton density sequences 1
• Maintain slice thickness ≤3 mm with in-plane spatial resolution of 1 × 1 mm (voxel size 3 × 1 × 1 mm) 1
• Field strength must be at least 1.5T, though higher field strengths reveal more new lesions 1

When to Use Contrast Enhancement

• Omit gadolinium in clinically stable patients on established treatment, as new or enlarging T2 lesions provide sufficient evidence of disease activity 1, 2
• Add contrast-enhanced T1-weighted sequences when: 2
  • Unexpected clinical presentations occur
  • Suspected treatment-related complications (especially PML screening)
  • New T2 lesions are detected and determining acuity would change management
  • Atypical symptoms not characteristic of MS develop

High-Risk Patient Monitoring

• For natalizumab-treated patients who are JCV seropositive with treatment duration ≥18 months, perform brain MRI every 3-4 months including FLAIR, T2-weighted, and diffusion-weighted imaging 1
• For JCV seronegative patients on natalizumab, annual brain MRI is sufficient 1
• When switching from natalizumab to other DMDs (fingolimod, alemtuzumab, dimethyl fumarate), perform MRI at treatment discontinuation and every 3-4 months for up to 12 months after starting new therapy 1

Spinal Cord Imaging

• Do not perform routine spinal cord MRI for monitoring, as brain imaging is more sensitive for detecting disease activity 1
• Reserve spinal cord imaging for unexplained or unexpected spinal cord symptoms 1, 2
• Most spinal cord lesions are clinically symptomatic, and strong correlation exists between new brain and spinal cord lesions 1

Disease-Modifying Therapy Review

Assessing Treatment Response

• Define treatment failure as ongoing clinical relapses and/or new MRI lesions (new T2 lesions or gadolinium-enhancing lesions) on follow-up scans performed 6-12 months after treatment initiation 1
• Allow 6 months for drugs like glatiramer acetate to become effective before judging response 1
• Consider the reference scan at 6 months post-treatment initiation rather than baseline to account for drug onset time 1

Monitoring for Adverse Effects

• Screen for infections, bradycardia, heart blocks, macular edema, infusion reactions, injection-site reactions, and secondary autoimmune effects (particularly thyroid disease) 4
• Use patient questionnaires to systematically assess treatment-related adverse effects that may compromise adherence 6

Adherence Assessment

• Address adherence at every visit, as perceived lack of efficacy and therapy-related adverse events are the primary factors driving non-adherence 7, 8
• Provide comprehensive patient education and support to maintain adherence 7
• Consider auto-injector devices for injectable therapies, as they reduce injection-site reactions and discomfort 7

Treatment Escalation Criteria

• Switch to more effective DMT when patients demonstrate continued disease activity despite current treatment, defined as new clinical relapses or new/enlarging MRI lesions 1
• Current DMDs reduce annualized relapse rates by 29-68% compared to placebo or active comparators 4
• Early identification of non-responders enables prompt escalation to more effective therapy 1

Relapse Management

Acute Treatment

• Administer corticosteroids as the mainstay treatment for MS relapses and initial presentations 3
• Reserve plasmapheresis for patients who do not adequately respond to steroids 3
• Perform MRI with gadolinium enhancement during unexpected clinical presentations to confirm acute inflammatory activity 2

Preventive Care

Lifestyle Modifications

• Strongly encourage tobacco cessation in all patients who smoke, as smoking accelerates disease progression 3

Multidisciplinary Support

• Coordinate care with physical and occupational therapists, speech and language therapists, mental health professionals, pharmacists, and dietitians 3
• Address quality of life issues proactively, as MS leads to physical disability, cognitive impairment, and decreased quality of life 4

Critical Pitfalls to Avoid

Imaging Interpretation Errors

• Do not misinterpret age-related periventricular capping or small vessel disease as MS lesions—MS lesions are ovoid, perpendicular to ventricles, and involve U-fibers 2
• Ensure minimum lesion size of ≥3 mm along main axis to maintain reproducibility 2
• Watch for "red flags" suggesting alternative diagnoses: snowball lesions (Susac syndrome), cloud-like corpus callosum lesions (NMOSD), or deep white matter lesions with cortical sparing (vascular disease) 2

Treatment Monitoring Errors

• Do not declare treatment failure before allowing adequate time for drug efficacy (minimum 6 months for some agents) 1
• Do not overlook carry-over opportunistic infections when switching therapies, particularly from natalizumab 1
• Maintain strict pharmacovigilance with frequent MRI scanning during therapy transitions 1