A late-breaking session at the 32nd Congress of the European Committee for Treatment and Research in Multiple Sclerosis (ECTRIMS; 14–17 September, London, UK) presented the Clinical Guideline on the pharmacological management of people with Multiple Sclerosis developed jointly by ECTRIMS and European Academy of Neurology (EAN).
This is the largest European collaboration to consider therapeutic guidelines for MS and have been developed following the GRADE methodology that implies a sequential assessment of the quality of evidence, followed by judgment about the balance between desirable and undesirable effects, and subsequent decision about the strength of a recommendation. The main recommendations presented by Susana Otero (Multiple Sclerosis Center of Catalonia, Barcelona, Spain) are based on the latest evidence available worldwide and have been agreed by a large working group of key MS experts across Europe, as well as patient representatives from MS advocacy groups, such as EMSP and MSIF.
New guidelines for patients with clinically isolated syndrome
One of the key consensus statements that has come out of the recent ECTRIMS/EAN meeting, concerns patients with clinically isolated syndrome. These are patients that have had only one neurological incident and do not fulfil current diagnostic criteria for MS.
Based on the available evidence and mindful that MS is a progressive disease and delay in starting disease modifying treatments can have long-term consequences, the steering committee has recommended that CIS patients with visible abnormalities on MRI scans should receive disease modifying drugs (DMD) prior to diagnosis.
Consensus on treating patients with established MS
Research advances over recent decades now means that clinicians have a large choice of effective drugs for the treatment of patient with confirmed MS. However, few of those drugs have been compared directly and the trial populations are too heterogeneous to draw direct comparisons.
The ECTRIMS/EAN steering group have therefore recommended that choosing the right drug for an individual patient with established MS should remain in the hands of the treating neurologist taking into account the patient’s history, their age, their level of disease activity, their comorbidities and, very importantly, their personal preferences. Drug choices may also depend on availability within different healthcare systems and different licencing regulations across Europe.
The experts within the committee hope that on-going and future trials may provide further clarity and recommendations will be made as time goes on, when the evidence on which to base them becomes available.
Guidelines on monitoring the effectiveness of MS treatments
The steering group did agree that, regardless the drug chosen regular monitoring should take place to investigate whether that treatment is having an impact on the disease.
“The timing of monitoring will depend on many factors and will differ between countries but the ideal is for patients to have an MRI scan about 12 months after starting a drug treatment. If there is a poor treatment response, then the treatment strategy should be to move on to a more aggressive drug,” comments Otero.
Guidelines for treating patients with Primary Progressive MS (PPMS)
PPMS is diagnosed in around 10–15% of MS patients and currently has no disease modifying pharmacological treatment. Ocrelizumab, a potential treatment for PPMS, has recently been tested in a phase 3 clinical trial and results have been very encouraging, but the drug is currently still under review by the European Medicines Agency.
The ECTRIMS/EAN steering group has recommended that PPMS patients should receive Ocrelizumab and this consensus statement will be included in the published guideline—but only if the drug is licenced before the publication date,” explains Otero.