The Canadian MS Working Group, under the aegis of the Canadian Network of MS Clinics, has released new recommendations on optimizing the treatment of multiple sclerosis (Freedman et al. Can J Neurol Sci 2020; online April 6, 2020; see link below). The paper updates the group’s prior recommendations published seven years ago (Freedman et al. Can J Neurol Sci 2013;40:307-323).
The 16 recommendations encompass risk stratification, criteria for switching patients with an inadequate response, cognitive testing, and treatment of pediatric-onset MS. The consensus recommendations were developed by 31 Canadian neurologists with expertise in MS.
The current version provides criteria for switching RRMS patients with an inadequate response to a disease-modifying therapy (DMT). A change in therapy is recommended if patients meet any of the major criteria. The major criteria are >2 relapses in the first year of treatment; relapse severity (moderate to severe, functional impairment and/or motor, cerebellar, brain stem or sphincter involvement); incomplete relapse recovery; and >3 new MRI lesions (T2 and/or T1 gadolinium-enhancing). This replaces the gauges used in the 2013 iteration to determine level of concern based on relapses, MRI lesions and EDSS worsening. With the present criteria, EDSS change (>1 point at 6 months) is not a separate category but is considered part of incomplete relapse recovery.
The recommendations emphasize the need to closely monitor treatment response so as to act promptly if breakthrough disease activity is identified. Annual MRIs are recommended in the first few years, with periodic imaging thereafter at the clinician’s discretion. Gadolinium contrast enhancement is advised for the initial and re-baseline scans but is not routinely required for follow-up scans. Cognitive assessments are recommended at baseline and every 2-3 years thereafter, although cognitive worsening is not a criterion for switching therapies.
Ongoing treatment is recommended for patients with secondary-progressive MS if they have active, inflammatory disease (relapses, new lesions). One treatment option is siponimod, although the Working Group noted that there are no data on whether patients on another DMT would benefit from a switch to siponimod. Ocrelizumab may be offered to patients with active primary-progressive MS (PPMS) and can be considered for patients without ongoing inflammation. The Working Group advised caution when considering treatment for PPMS subgroups that would be less likely to benefit, such as older patients and those with significant neurological deficits.
The Working Group also addressed the emerging issue of stopping therapy, recommending that treatment discontinuation be considered in RRMS patients aged >60 years who have been clinically stable for 5-10 years. Stopping may also be considered in progressive MS patients aged >60 years with no new inflammatory activity for >5 years.
The full text of the Canadian MS Working Group treatment optimization recommendations can be downloaded for free at https://www.cambridge.org/core/services/aop-cambridge-core/content/view/6F71BA9F915D7AC1228BBB52EF3B8AD7/S0317167120000669a.pdf/treatment_optimization_in_multiple_sclerosis_canadian_ms_working_group_recommendations.pdf).
(Full disclosure: NeuroSens staff provided logistic and editorial support during the development of the treatment optimization recommendations.)