Multiple Sclerosis Management

Introduction

Multiple sclerosis (MS) is a chronic and often disabling autoimmune disease that requires comprehensive management, including disease-modifying therapy (DMT), symptom management, and lifestyle modifications, as recommended by the American Academy of Neurology and the National Multiple Sclerosis Society 1

The American Academy of Neurology recommends early intervention to prevent accumulation of disability in patients with MS, with selection of DMT based on disease subtype, disease severity and activity, patient characteristics, and risk tolerance 1
For mild-moderate disease, oral agents such as dimethyl fumarate, teriflunomide, and fingolimod, as well as injectable therapies like interferons and glatiramer acetate, are considered, according to the National Multiple Sclerosis Society 1
In cases of highly active disease, monoclonal antibodies like natalizumab, ocrelizumab, and ofatumumab are recommended, with consideration of natalizumab with appropriate JCV antibody monitoring, as suggested by the European Committee for Treatment and Research in Multiple Sclerosis 1
For treatment-refractory disease, autologous haematopoietic stem cell transplantation (AHSCT) is considered after failure of high-efficacy DMTs, as recommended by the International Society for Stem Cell Research 1

AHSCT is most effective in relapsing-remitting MS (RRMS) and early secondary progressive MS, with benefits less clear in primary progressive MS, according to the Multiple Sclerosis International Federation 1
AHSCT is recommended for aggressive forms of relapsing-remitting MS after failure of high-efficacy DMTs, and for rapidly evolving, severe, treatment-naive MS on a case-by-case basis 1

Siponimod and ocrelizumab are recommended for secondary progressive MS with activity, with consideration of AHSCT in early stages with inflammatory activity, as suggested by the National Institute of Neurological Disorders and Stroke 1

Ocrelizumab is recommended for primary progressive MS, with benefits of AHSCT less clear, according to the European Multiple Sclerosis Platform 1

Clinical monitoring is essential, with evaluation every 3-6 months initially, then every 6 months, to assess for new symptoms, relapses, and disability progression, as recommended by the American Academy of Neurology 1
Common pitfalls in MS management include delaying treatment initiation in active disease, inadequate monitoring of treatment response, and overlooking symptom management while focusing only on disease modification 1

Baseline MRI before initiating therapy, followed by regular MRIs at intervals (typically annually), using standardized protocols with gadolinium enhancement to identify active inflammatory lesions, is recommended by the International Society for Magnetic Resonance in Medicine 1
T2-weighted spin echo sequences are more sensitive for demonstrating MS lesions 2
Gadolinium enhancement should be used to identify active inflammatory lesions, with standardized protocols including 5 mm slice thickness, 256 x 256 matrix, and scanning starting at least five minutes after gadolinium injection 2

Drug-specific monitoring protocols and JCV antibody testing for patients on natalizumab are essential, according to the National Multiple Sclerosis Society 1
Cerebrospinal fluid analysis is recommended in patients with suspected MS where clinical and MRI findings are insufficient for diagnosis, and is useful for cases with atypical presentations or possible alternative diagnoses 3
Key biomarkers include oligoclonal bands, neurofilament light chain (NfL), and glial fibrillary acidic protein (GFAP) 3

A comprehensive approach to symptom management is essential for quality of life, including management of spasticity, fatigue, balance and gait, bladder and bowel dysfunction, sexual dysfunction, cognitive dysfunction, depression, and pain, as recommended by the Multiple Sclerosis Association of America 1

Implementation of MS Care Units with a core team of MS neurologists, MS nurses, neuropsychologists, physical therapists, and occupational therapists, as well as an extended team of specialists, is recommended for optimal management, according to the European Multiple Sclerosis Platform 1

Discussing family planning early, with consideration of DMT discontinuation and washout periods before conception, is essential, as recommended by the American College of Obstetricians and Gynecologists 1

Focus on symptom management and function preservation, with limited DMT options, but consideration of ocrelizumab for primary progressive MS, and rehabilitation as crucial, according to the National Institute of Neurological Disorders and Stroke 1
Reassessing diagnosis and adherence, considering switching to higher efficacy DMT, and considering AHSCT in appropriate candidates, is recommended by the International Society for Stem Cell Research 1
Failing to address psychological aspects of the disease and not considering AHSCT for appropriate candidates with aggressive disease are also potential mistakes 1
Misinterpreting CSF findings without clinical context can lead to incorrect diagnosis or treatment 3