Multiple Sclerosis

- Executive Summary

The scope of these guidelines is to provide practical recommendations for the diagnosis and treatment of MS based on current scientific evidence.

▶️ Acute MS relapses should be diagnosed when the patient develops symptoms that occur over a minimum of 24 hours and separated from a previous attack by at least 30 days, in the absence of fever or infection. In the radiological domain, the criteria for relapses are defined as an increase in lesion load/size on T2 imaging or gadolinium enhancement of lesions on magnetic resonance imaging (MRI) in the brain or spinal cord.

▶️ It is recommended to treat initially acute MS relapses with a 3–5 day course of intravenous methylprednisolone.

▶️ The diagnosis of relapsing remittent multiple sclerosis (RRMS) should be promptly considered after the patient experiences the first symptoms that may be suggestive of MS relapse, what is termed as clinical isolated syndrome (CIS).

▶️ RRMS should be diagnosed if there is a proof for dissemination in space (DIS) and dissemination in time (DIT). DIS is proved if there is one or more lesion in each of two or more of the four following areas: periventricular, cortical/juxtacortical, infratentorial, and spinal cord, taking into consideration that symptomatic lesions can be used to demonstrate DIS. DIT is proved if there is simultaneous presence of gadolinium enhancing and non-enhancing lesions at any time, or if a new T2 lesion on follow up MRI irrespective of timing of baseline scan, or the demonstration of cerebrospinal fluid oligoclonal bands in the absence of atypical CSF findings.\

▶️ Neurologists should counsel patients with MS that DMTs are prescribed to reduce relapses and new MRI lesion activity, and should counsel on the importance of adherence to DMT.

▶️ Neurologists must ascertain and incorporate/review preferences in terms of safety, route of administration, accessibility of the drug, efficacy, common adverse effects, and tolerability in the choice of DMT in MS patients.

▶️ Neurologists should monitor the reproductive plans of women with MS and counsel regarding reproductive risks and use of birth control during DMT use in women of childbearing potential who have MS (6) (strong recommendation) (high quality evidence).

▶️ Neurologists could prescribe highly effective DMTs (such as fingolimod, cladribine, natalizumab, or ocrelizumab) from the beginning for highly active MS patients and aggressive MS patients.

▶️ Neurologists should monitor MRI disease activity from the clinical onset of disease to detect the accumulation of new lesions in order to inform treatment decisions in people with MS using DMTs.

▶️ Neurologists should discuss switching from one DMT to another in MS patients who have been using a DMT long enough for the treatment to take full effect and are adherent to their therapy when they experience 1 or more relapses, 2 or more unequivocally new MRI-detected lesions, or increased disability on examination, over a 1-year period of using a DMT.

▶️ Neurologists should offer siponimod for active SPMS patients evidenced by relapses or imaging-features of inflammatory activity.

▶️ Neurologists should offer ocrelizumab for PPMS patients.