MS guidelines by Spanish society stress early, effective treatment

Neurologists move to favor starting high-risk patients on high-efficacy therapies

Marisa Wexler, MS avatar

by Marisa Wexler, MS |

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New guidelines from the Spanish Society of Neurology emphasize the importance of early diagnosis and prompt treatment in the management of people with multiple sclerosis (MS).

These guidelines also highlight a need to move beyond traditional views of “first line” and “second line” MS treatments, suggesting instead a personalized approach that favors more aggressive therapies being used earlier in patients at higher risk of poor outcomes.

The study, “Consensus statement of the Spanish Society of Neurology on the treatment of multiple sclerosis and holistic patient management in 2023,” was published in Neurología.

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MS treatment needs to move beyond first- and second-line approaches

This is the fourth iteration of MS-specific guidelines put out by the Spanish Society of Neurology’s Demyelinating Diseases Study Group. The first version was released in 2010, with updates published in 2013 and in 2017.

Much in the latest version remains similar to previous recommendations. For example, because available treatments can slow MS progression but cannot reverse damage that’s already accumulated, these guidelines still emphasize the importance of making an accurate diagnosis as early as possible so that appropriate treatment can be initiated promptly.

But the new guidelines also take into account the changing landscape of MS, with numerous recently approved high-efficacy therapies and a growing body of knowledge on different treatment strategies.

One of the main changes is a revision in how MS treatments are classified. Available MS medications can be broadly broken into two categories: older therapies that are usually quite safe but less potent than newer medicines, and newer high-efficacy therapies that carry more substantial safety risks.

Traditionally, patients have been given “first-line treatment” with safer, moderate-efficacy medicines. Then, if these treatments are found wanting, patients could escalate to “second-line treatment” with higher-efficacy therapies.

But in the last few years, numerous studies have shown that patients who start on high-efficacy treatment tend to have less severe disability progression over time, compared with patients who initially start on moderate-efficacy therapies.

Although no clinical trials have directly compared these two approaches to show that starting high-efficacy treatment earlier is better, available data suggest this “consistently and with an acceptable level of evidence,” the researchers said.

As such, the new guidelines suggest that high-efficacy therapies, traditionally considered “second-line treatment,” may be given as the initial therapy. The scientists especially recommend starting high-efficacy treatment early for patients with factors associated with a worse prognosis, such as male sex, a history of smoking, other co-occurring health problems, or aggressive MS (e.g., multiple relapses in the first year after disease onset, or a lot of disease activity visible on MRI scans).

“We should stress the need to abandon the classical terminology of ‘lines of therapy,’ as the drugs previously considered to be ‘second-line’ are high-efficacy treatments that may be considered as a first option, according to the characteristics of the patient and their disease,” the scientists wrote.

Updated guidelines into treatment of CIS, patients planning a pregnancy

Studies in recent years also have shown that patients with clinically isolated syndrome (CIS) — an initial attack of MS-like disease — are less likely to go on to develop MS if they receive treatment with MS medications. Similar findings are reported for people with radiologically isolated syndrome (RIS), which refers to MS-like nerve damage found incidentally on brain scans without notable symptoms.

Based on these findings, the guidelines suggest that patients with CIS or RIS should be offered treatment at the earliest opportunity. Treatment, again, is particularly recommended for those with other poor prognostic factors.

Regardless of disease type, patient perspectives should be considered at all stages of disease management. The guidelines recommend using patient-reported measures regularly to have a better sense of a person’s experiences with the disease and to adjust treatment as needed.

The new guidelines also emphasize the importance of getting all recommended vaccines before starting on MS therapies that can weaken the immune system. Its scientists noted that accurate information about vaccines is especially important in light of the COVID-19 pandemic.

The 2023 guidelines also offer new recommendations concerning MS care for people who plan to become pregnant. The guidelines suggest treating these patients so their MS is stable, without new disease activity, for at least a year before they try for a pregnancy. Then, routine MRI scans should be avoided during pregnancy to prevent damage to the fetus.

There’s still not a lot of data on the use of most MS treatments during pregnancy, so decisions about continuing treatment (especially in unplanned pregnancies) need to be made on a case-by-case basis depending on the patient’s specific situation. The guidelines note that, if MS treatment is paused during pregnancy, treatment should be restarted as soon as possible after the baby is born.