Canadian MS Working Group Updates Guidelines for Diagnosis, Treatment

The Canadian MS Working Group (CMSWG) — made up of neurologists with the Canadian Network of MS Clinics — has updated its recommendations concerning diagnosis and the use of disease-modifying therapies (DMTs) for multiple sclerosis (MS), according to a press release from the MS Society of Canada.

The 16 new recommendations contained in “Treatment Optimization in Multiple Sclerosis: Canadian MS Working Group Recommendations” were published in the Canadian Journal of Neurological Sciences.

CMSWG last released guidelines for MS management in 2013. Since then, new diagnostic criteria have been introduced, and multiple DMTs have been approved, including some indicated for progressive forms of MS — namely Ocrevus (ocrelizumab) for primary progressive MS (PPMS), together with Mayzent (siponimod) and Mavenclad (cladribine) for active secondary progressive MS (SPMS).

These recommendations aim to provide guidance to professionals treating MS patients, according to the MS Society of Canada, and span “starting, monitoring, and switching therapies to ensure that people are receiving the most optimum treatment.”

Guidelines favor an MS diagnosis using the 2017 McDonald criteria, which allows for an earlier and more accurate diagnosis than previously.

Before beginning treatment, the recommendations note the importance of appropriate screening, which may include evaluations of the immune system, liver function, pregnancy tests, and ensuring that vaccinations are up-to-date.

Treatment, the group advises,  favor DMTs started soon after a person is diagnosed with relapsing MS (relapsing-remitting MS and active SPMS). Risk evaluation, based on clinical and demographic parameters, should be done on an ongoing basis to guide treatment decisions.

Beyond MS-specific DMTs, the recommendations also favor including wellness efforts, like encouraging a stop to smoking or regular exercise, in treatment plans. They stress that treatment plans also account for other health conditions.

For people with active PPMS, the recommendations suggest treatment with Ocrevus. However, they note that this decision should account for its potential benefits and risks. In particular, caution is recommended for people who are less likely to benefit from treatment: those age 55 and older, or with significant neurological problems.

For individuals transitioning to SPMS, the recommendations suggest ongoing treatment with the current DMT. New relapses or brain lesions may warrant medication changes.

Several of the recommendations stress the importance of close, routine monitoring for people with MS, including regular assessments of cognition, disability status, and brain imaging via an MRI scan.

For people with relapsing forms of MS, response to treatment should be evaluated early, and treatment should be switched within the first two years if the response is not optimal — e.g., a relapse within the first two years of treatment, or a new MRI lesion.

Most relapsing MS patients will be treated with more than one DMT during the course of their disease. As such, the recommendations suggest that escalation to a more potent medication be undertaken with individuals meeting certain criteria, such as two or more relapses in the first year or the appearance of at least three new brain lesions on MRI.

“When sequencing therapies, clinicians should recognize that a given therapy may have an impact on future treatment choices,” the guidelines state. “Prior to initiating treatment, the clinician should develop a plan as to how medications might be sequenced so that safety concerns or other factors will not limit subsequent treatment options or delay the initiation of the next DMT.”

Woman of childbearing age should be encouraged to use “a reliable method of contraception” or birth control, the recommendations state. For those planning a  pregnancy, waiting until disease stabilization is favored, as DMT use be need to be stopped prior to conception. Certain DMTs may not be appropriate due to possible effects on fetal development or risks of stopping a medication during pregnancy.

For children with MS (pediatric-onset MS, abbreviated as POMS), the recommendations suggest early treatment and close monitoring.

“All DMTs approved for the adult population have been used in POMS and are likely to be efficacious,” the recommendations state. “Treated children and adolescents with MS should be monitored comprehensively, with standardized monitoring according to the specific DMT.”

Broadly, these recommendations stress the importance of shared decision-making between clinicians and patients when designing a treatment plan, including the importance of ensuring that patients are fully aware of the potential risks associated with any given treatment strategy.

“Treatment decisions must necessarily be based on a rational assessment of the individual patient’s benefits and risks,” the recommendations state. “Throughout this process, the patient should be fully informed of the goals of therapy, the reasons for intensifying therapy, and the potential adverse effects. Consideration must be given to the patient’s preferences to encourage a collaborative approach to therapy.”