Click here to watch Dr. Julie Prévost discuss the case and the responses to the survey.

Michelle, 46, is a bank manager who was diagnosed with MS in 1996. She was initially treated with interferon-beta-1a 44 ug. She experienced ongoing clinical and radiological activity and was switched to natalizumab in 2013. She remained stable for seven years. In February 2020, Michelle noted that she used to be able to walk 2 km but could now only manage about 1 km. Her EDSS score showed no change over the past year. EDSS score was 3.0 (motor 2, cerebellar 2, sensory 2). She was started on 4-aminopyridine but obtained no benefit.

A year later, Michelle reported that she had become more sedentary during the pandemic. She said that was partly due to greater leg weakness, making it difficult for her to walk >500 metres unaided. She was fully vaccinated against COVID-19 and was seen in person. EDSS score was 3.5 (motor 3, cerebellar 2, sensory 2). Michelle said she had not experienced any relapses. MRI of the brain/spine was stable.

At her most recent visit, Michelle said she has been relapse-free but has been experiencing worsening symptoms (e.g. bladder issues). She has been having difficulty concentrating which had caused problems at work. She said that her mobility has worsened, and she can only walk 300 metres unaided. MRI is unchanged.

The survey is now closed. We received 30 responses. See below for a summary of the answers you provided.

Question 1: In your opinion, has Michelle transitioned to secondary-progressive MS?
A majority of respondents (76.7%) thought that she had transitioned to SPMS, 6.7% said she had not, and 16.7% were unsure.

Question 2: What is your main criterion for diagnosing SPMS?
Most respondents (66.7%) use the criterion of worsening disability without disease activity. About one-quarter (23.3%) said their criterion was an increase in EDSS score with worsening symptoms. About 7% use the benchmark of EDSS >4.0; no respondent used the benchmark of EDSS >6.0.

Question 3: Would you initiate siponimod in this patient?
A majority of respondents (75.9%) would consider using siponimod since it may provide some benefit even in patients with inactive SPMS. Another 6.9% would use siponimod since Michelle has transitioned to SPMS. 17.2% said they would not use siponimod because her SPMS is inactive.

Question 4: What would be your preferred treatment approach?
The preferred treatment approach for most respondents (56.7%) was an anti-CD20 agent. Some would maintain natalizumab (     16.7%), and some would switch to siponimod (13.3%) or oral cladribine (6.7%).

Question 5: Would you consider discontinuing treatment in this patient?
Most respondents (51.7%) would not discontinue treatment because of the age of the patient, or because treatment will reduce ongoing disease activity even during the progressive phase (24.1%). A few respondents (6.9%) said they would stop treatment since it will provide little benefit, and 17.2% said they would stop treatment if the patient requested it.

View the video commentary from Dr. Julie Prévost.