Treatment Optimization in Multiple Sclerosis

Abstract

The treatment of multiple sclerosis has finally become possible with the advent of the current disease-modifying therapies (DMTs) that have had a significant impact on those living with this disease. Though demonstrating clear efficacy on a number of short-term outcome measures, unfortunately, these agents are not “cures” and many patients with multiple sclerosis continue to experience disease activity in spite of treatment. Clinicians are becoming more comfortable initiating therapy with DMTs, but it is now important to focus attention on monitoring the results of the chosen therapy and deciding whether or not a patient is responding well to treatment. At present, however, clinicians lack criteria for defining optimal versus suboptimal responses to DMTs as well as evidence-based guidelines on how to improve treatment outcomes. Using a recently published model as a framework, The Canadian Multiple Sclerosis Working Group developed practical recommendations on how neurologists can assess the status of patients on DMTs and decide when it may be necessary to modify treatment in order to optimize outcomes. The Canadian Multiple Sclerosis Working Group's recommendations are based on monitoring relapses, neurological progression and MRI activity. Other possible causes of suboptimal treatment responses or treatment failure are also considered.

Optimizing outcomes in multiple sclerosis: consensus guidelines for the diagnosis and treatment of multiple sclerosis in Latin America

“…A relapse is the development of signs or symptoms that persist at least for 24 h. Further to the duration of relapses, it is important to determine their frequency, severity, and subsequent recovery [Freedman et al 2004]. Relapse frequency must be considered in association with pretreatment patient history.…”

“…A resource that has proved effective to this extent is the Multiple Sclerosis Severity Score. Freedman and colleagues combined the criteria of relapse frequency and severity with subsequent recovery, and established an assessment model that classifies them into three different categories [Freedman et al 2004]. The panel further discussed the convenience and need to take an MRI scan during relapses.…”

Therapeutic strategies in childhood multiple sclerosis

“…As no medication prevents the risk of a new attack by 100%, in clinical practice it is not simple to decide whether to continue the treatment with the same drug in a patient who continues to have relapses. Clinical findings (number or relapses, frequency of relapses during the treatment compared to the pretreatment phase, increase of EDSS score), and MRI data (new T2 lesions, Gdþ lesions) have been included as criteria to define treatment failure, but at present no consensus has been reached on the use of clinical or MRI markers [Portaccio et al 2006;Rio et al 2006;Freedman et al 2004].…”

Review of the Clinical Debate Regarding Interventions for Multiple Sclerosis

“…26, [74][75][76] Recognizing the Need to Switch Therapies If a patient with MS has what is deemed to be an inadequate response to therapy, then switching to another DMT should be considered. Several studies have been conducted to examine the need for and results of switching from one DMT to another.…”

“…26, [74][75][76] In addition to frequency of relapses, worsening neurologic impairment may also indicate a suboptimal response to MS therapy. For example, an annual increase in EDSS score of at least 1 point from a previous score of 3.0 to 5.5, or a 0.5-point increase …”