Multiple Sclerosis (MS)

Guideline recommendations have been developed and published for the diagnosis and treatment of multiple sclerosis (MS), as well as the management of aspects of the disease. 

MS Diagnostic Guidelines

The Consortium of Multiple Sclerosis Centers (CMSC), the Magnetic Resonance Imaging in MS (MAGNIMS) network, and the European Academy of Neurology (EAN) have issued guidelines for the use of imaging in the diagnosis of MS.^1-3 According to all 3 organizations, magnetic resonance imaging (MRI) should be used to confirm a diagnosis of MS and monitor disease progression. 

According to the CMSC, high-resolution, 3-dimensional imaging should be used whenever possible.¹ The group recommends that brain MRI with gadolinium be performed at baseline. It also recommends that spinal cord MRI be performed in patients with an inconclusive result on brain MRI or with presenting symptoms at the level of the spinal cord, and in patients aged more than 40 years with nonspecific brain MRI findings.

According to the recommendations, cervical cord MRI should be done simultaneously with brain MRI in patients with or without transverse myelitis. In case the patient has severe optic neuritis with poor recovery, an orbital MRI should be performed. The CMSC recommends follow-up brain MRI every 6 to 12 months for patients with high-risk clinically isolated syndrome (CIS), and every 12 to 24 months for those with low-risk CIS.

The MAGNIMS network recommends spinal cord MRI in patients with spinal cord symptoms at disease onset and whose brain MRI results are inconclusive, or if the brain MRI suggests radiologically isolated syndrome.² The network recommends more frequent monitoring (every 3 to 6 months) for patients with radiologically isolated syndrome or CIS and abnormal MRI findings. 

To monitor patients with an established diagnosis of MS, the MAGNIMS network recommends T2-weighted and contrast-enhanced T1-weighted brain MRI. It also recommends assessing patients’ brain volume because volume loss can be a good predictor of long-term disability. For patients who switch between disease-modifying therapies, MRI every 3 to 6 months for up to 12 months is recommended to screen for opportunistic infections and unexpected disease activity.

MS Disease-Modifying Treatment Guidelines

Practice guidelines have been published by the American Academy of Neurology (AAN) to help health care professionals and patients with MS decide between the disease-modifying therapies that are currently available. The guidelines aim to help health care providers consider the benefits and risks of each of the large number of therapies available, especially for relapsing-remitting MS, and recommend treatments to their patients while taking into account their lifestyle and reproductive choices.

The guideline titled “Practice Guideline Recommendations Summary: Disease-Modifying Therapies for Adults With Multiple Sclerosis,” published in April 2018, provides information about different types of therapies and published evidence of their effectiveness in reducing relapses and slowing disease progression, as well as their potential risks.⁴ The recommendations were developed by MS experts and patients living with the disease and are endorsed by the CMSC, the Multiple Sclerosis Association of America (MSAA), and the National Multiple Sclerosis Society.

The guideline includes 17 recommendations about starting disease-modifying treatments, 10 recommendations about switching between disease-modifying treatments, and 3 recommendations about stopping disease-modifying treatments. The AAN also has published patient-friendly summaries of the guidelines for starting, stopping, and switching therapies.

The guideline states that because the field of MS treatment is rapidly changing, the recommendations may have to be re-analyzed and updated in the near future.

MS Management Guidelines

Also published by the AAN are practice guidelines on immunization and vaccine-preventable infections in MS, as well as evidence-based guidelines on complementary and alternative medicine in MS.

The vaccine-preventable infections and immunization guidelines include recommendations about optimal immunization strategies in line with each patient’s disease status, values, and preferences; the annual influenza vaccination; vaccination before the initiation of immunosuppressive or immunomodulatory treatment; vaccination of patients with latent infections, such as hepatitis and tuberculosis; the use of live attenuated vaccines; and the timing of vaccinations.⁵ The CMSC and the MSAA have endorsed the guidelines regarding vaccine-preventable infections and immunization in MS.

The guideline on complementary and alternative medicine compares the efficacy of various complementary and alternative medicine therapies in reducing the symptoms of MS and preventing relapses or disability.⁶ Information is included about oral cannabis extract and synthetic tetrahydrocannabinol, oromucosal cannabinoid spray, smoked cannabis, Ginkgo biloba, dietary supplementation with omega-3 fatty acids, and the Cari Loder regime (lofepramine plus L-phenylalanine with vitamin B12), as well as bee sting, magnetic therapy, and reflexology. The CMSC and the International Organization of Multiple Sclerosis Nurses have endorsed the guideline.

References

1. Traboulsee A, Simon JH, Stone L, et al. Revised recommendations of the Consortium of MS Centers Task Force for a standardized MRI protocol and clinical guidelines for the diagnosis and follow-up of multiple sclerosis. AJNR Am J Neuroradiol. 2016;37(3):394-401. doi:10.3174/ajnr.A4539
2. Rovira A, Wattjes MP, Tintoré M, et al. MAGNIMS consensus guidelines on the use of MRI in multiple sclerosis—clinical implementation in the diagnostic process. Nat Rev Neurol. 2015;11(8):471-482. doi:10.1038/nrneurol.2015.106
3. Filippi M, Rocca MA, Arnold DL, et al. EFNS guidelines on the use of neuroimaging in the management of multiple sclerosis. Eur J Neurol. 2006;13(4):313-325. doi:10.1111/j.1468-1331.2006.01543.x
4. Rae-Grant A, Day GS, Marrie RA, et al. Practice guideline recommendations summary: disease-modifying therapies for adults with multiple sclerosis: report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology. Neurology. 2018;24;90(17):777-788. doi:10.1212/WNL.0000000000005347
5. Farez MF, Correale J, Armstrong MJ, et al. Practice guideline update summary: vaccine-preventable infections and immunization in multiple sclerosis: report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology. Neurology. 2019;24;93(13):584-594. doi:10.1212/WNL.0000000000008157
6. Yadav V, Bever C, Bowen J, et al. Summary of evidence-based guideline: Complementary and alternative medicine in multiple sclerosis: report of the guideline development subcommittee of the American Academy of Neurology. Neurology. 2014;82(12):1083-1092. doi: 10.1212/WNL.0000000000000250

Reviewed by Michael Sapko, MD, on 7/1/2021.

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Ozge Ozkaya, MSc, PhD

Özge’s background is in research; she holds a MSc. in Molecular Genetics from the University of Leicester and a PhD. in Developmental Biology from the University of London. Özge worked as a bench scientist for six years in the field of neuroscience before embarking on a career in science communication. She worked as the research communication officer at MDUK, a UK-based charity that supports people living with muscle-wasting conditions, and then a research columnist and the managing editor of resource pages at BioNews Services before joining Rare Disease Advisor.