Selected highlights from CMSC 2023


The Consortium of MS Clinics (CMSC) annual meeting concluded on June 3, 2023. The following are some selected highlights from the symposium.

De-escalating DMTs: A study at the Cleveland Clinic examined the impact of de-escalating treatment to a lower-efficacy DMT (Goldschmidt et al. CMSC 2023;DMT01). A total of 135 patients were switched from a moderate-efficacy treatment (dimethyl fumarate, fingolimod) to an injectable (glatiramer acetate, interferon-beta). De-escalating therapy was not associated with clinical or MRI worsening. Overall, injectable therapies were not inferior to oral drugs in this analysis. Additional research is needed to examine the safety of de-escalating from a higher-efficacy DMT to an alternative DMT.

Slow adoption of standardized MRI protocol: Several groups have developed recommendations in recent years on the use of MRI in the diagnosis and management of MS; the most recent are the MAGNIMS-CMSC-NAIMS recommendations (Wattjes et al. Lancet Neurol 2021;20:653-670). In 2020, the British Columbia Medical Imaging Advisory Committee recommended the adoption of an earlier iteration (Traboulsee et al. AJNR Am J Neuroradiol 2016;37:394-401) province-wide. A survey in 2022 found that only 53.8% of MRI centres were fully compliant with the guidelines (Li et al. CMSC 2023;IMG01). This represented a substantial increase from the adoption rate in 2019 (13.3%), but was still far from optimal. The B.C. group said they hope to use the survey results to encourage improved compliance with MRI guidelines.

The CMSC also noted problems with compliance with MRI guidelines (Dewey et al. CMSC 2023;IMG07). In the Traditional Versus Early Aggressive Therapy for MS (TREAT-MS) Trial, only 14.7% of MRIs adhered to CMSC guidelines during the screening period. During the study itself, compliance with imaging protocols was 54.2%. The most common problems were slice thickness and slice gap. The group noted that failure to adhere to imaging protocols makes it more difficult to harmonize data across sites and produce consistent results.

High incidence of herpes zoster in MS patients: A retrospective cohort study examined the incidence of herpes zoster (HZ) infection in MS patients versus the general population (Stempniewicz et al. CMSC 2023;EP109). The study used health claims data for MS patients from the U.S. for the period 2015-2022 (n=42,185) and compared it to a random sample of 1 million healthy individuals. The MS cohort was categorized as having no (53%), low (35%) and high (10%) immunosuppression. The overall incidence of HZ was 13.78 per 1000 patient-years (PY) in MS patients: 11.61/1000 PY for patients <50 years and 15.16/1000 PY for those aged >50 years. The HZ incidence in healthy controls was 5.64/1000 PY (3.46 for ages <50 years, 8.57 for ages >50 years). The HZ incidence among MS patients increased substantially with the level of immunosuppression: the incidence rates were 12.97/1000 PY with no immunosuppression, 14.03/1000 PY for low immunosuppression, and 18.0/1000 PY for high immunosuppression.

Increasing body weight during MS clinical course: The Cleveland Clinic tracked changes in body-mass index (BMI) in a cohort of MS patients (N=949) from the MS PATHS registry (Conway et al. CMSC 2023;QOL11). BMI was obtained within two years of diagnosis and 1-3 years later. Mean age was 39.8 years. The mean initial BMI was 29.7; 70.4% were overweight/obese at entry (defined as BMI >25). Mean BMI at two-year follow-up was 30.1; the proportion classified as overweight/obese was 73.7%. In the overweight/obese subgroup, 55.3% had a >0.5-point increase in BMI at two years.

A separate analysis from the MS PATHS registry reported that BMI was associated with disability level (Patient Determined Disease Steps) (Harris et al. CMSC 2023;QOL20). Patients with moderate and high levels of disability had a higher BMI at baseline compared to those with minimal disability. It is unclear to what extent obesity itself influenced disability assessments. During the two-year follow-up, weight gain was similar in the three groups. The authors concluded that there are opportunities for weight management for all MS patients regardless of disability level.

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