Updated EAN-ECTRIMS guideline on pharmacological MS treatment

The new EAN-ECTRIMS guideline includes the advice to treat young secondary progressive multiple sclerosis (SPMS) patients with siponimod or anti-CD20 monoclonal antibodies, regardless of the lack of evidence on efficacy, safety, and tolerability. Additionally, starting earlier with higher-efficacy disease modifying drugs (DMDs) is suggested when treating patients with unfavourable prognosis. If a high-efficacy DMD treatment is terminated, a different high-efficacy DMD should be started. The radiologically isolated syndrome (RIS) is not however included in the guideline, due to a lack of evidence.

The new EAN-ECTRIMS guideline “Update on the pharmacological treatment of people with multiple sclerosis” was presented at the EAN 2022 meeting [1]. Prof. Maria Pia Amato (University of Florence, Italy) summarised the main questions the guideline addresses.

The 5 core topics of the guideline include:

1. Efficacy of DMDs.
2. Early treatment decisions.
3. Disease/treatment response monitoring and treatment modification.
4. Treatment suspension and disease reactivation.
5. Pregnancy and breastfeeding.

Added to these were 3 practical topics:

6. Treatment safety and its monitoring.
7. Disease-modifying therapy (DMT) switching strategies.
8. Long-lasting effects of DMTs (alemtuzumab and cladribine).

The guideline supports not only early start of MS treatment but also early start of a higher-efficacy DMDs, depending on the degree of disease activity, either clinically or on MRI, and patient characteristics. This is an important difference from the previous edition of this guideline, Prof. Amato stressed. “It is an important message of this guideline that you should not lose time when treating a patient with an unfavourable prognosis, by giving them only moderately effective drugs.”

When treatment with a high-efficacy DMD is terminated for whatever reason, the guideline suggests starting another high-efficacy DMD, taking into account factors like clinical and MRI disease activity, pharmacokinetics, and the risk of resumed disease activity or even rebound (especially in natalizumab or S1P modulators). Prof. Amato added: “When a patient is stable and has no safety or tolerability issues, consider continuing treatment with a DMD, taking into account patient characteristics and comorbidities, drug safety profile, family planning, and patient values and preferences.”

Prof. Amato explained that a big part of the discussion was about recommendations regarding treatment of SPMS without evidence of inflammatory activity (relapses and/or MRI activity). “Particularly in young SPMS patients and those in whom progression has started recently, treatment with siponimod or anti-CD20 monoclonal antibodies should be considered, even though only scarce evidence is present to support their use in this setting, as well as the safety and tolerability profile of these drugs.”

When asked about radiologically isolated syndrome (RIS), Prof. Amato said treatment of RIS is not included in the guideline because evidence from clinical trials is lacking; there are however RIS trials ongoing with teriflunomide, dimethyl fumarate, and ocrelizumab.

1. Amato MP. Getting Evidence into practice: The new EAN-ECTRIMS guideline “Update on the pharmacological treatment of people with multiple sclerosis”. SYMP02, EAN 2022, 25–28 April, Vienna, Austria.

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Posted on 22 August 202225 March 2024