CLINICAL CASES IN MS – A case of worsening mobility during the pandemic


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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.

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Question 1: In your opinion, has Michelle transitioned to secondary-progressive MS?

Question 2: What is your main criterion for diagnosing SPMS?

Question 3: Would you initiate siponimod in this patient?

Question 4: What would be your preferred treatment approach?

Question 5: Would you consider discontinuing treatment in this patient?

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