ECTRIMS/EAN Clinical Guidelines on MS treatment: an update

At a joint session on behalf of ECTRIMS and the European Academy of Neurology (EAN), an update was presented of the ECTRIMS/EAN Clinical Guidelines on the treatment of people with MS. At the time of the presentation, this document had not yet been published [1].

Prof. Xavier Montalban (Vall d’Hebron University Hospital, Spain) summarised the 2021 update of the ECTRIMS/EAN guidelines. The update is divided into 8 topics, of which the first is efficacy of disease-modifying therapy (DMT). The following recommendations were included:

• Offer interferon or glatiramer acetate to patients with clinically isolated syndrome (CIS) highly suggestive of MS and an abnormal MRI with lesions suggestive of MS who do not fulfil criteria for MS.
• Offer treatment with siponimod to patients with secondary progressive MS (SPMS) with evidence of inflammatory activity (relapses and/or MRI activity). Treatment with other DMTs used for relapsing MS may also be considered, taking into account their efficacy, the patient's expectations, as well as safety and tolerability issues.
• Consider treatment with siponimod or anti-CD20 monoclonal antibodies for patients with SPMS without evidence of inflammatory activity, particularly in young patients and those in whom progression has started recently.
• Consider ocrelizumab for patients with primary progressive MS (PPMS), particularly in early and active (clinically and/or radiologically) disease.
• Consider treatment with mitoxantrone in patients with active SPMS when there is no other therapy available, taking into account –in discussion with the patient– its efficacy and specifically the well-documented, concerning, safety issues and tolerability profile.

Topic 2 comprised early treatment decisions. One of the recommendations is to consider choosing a higher efficacy DMT early on, according to disease activity (either clinically or on MRI) and patient particulars.

Topic 3 is disease/treatment response monitoring and treatment modifications. The central recommendation in this topic is to offer a more efficacious drug to patients treated with DMTs who show evidence of disease activity.

Topic 4 is concerned with suspension of treatment and disease reactivation. Prof. Montalban highlighted these 2 recommendations:

• When treatment with a high-efficacy DMT is stopped, either due to inefficacy or risk of adverse events, consider starting another high-efficacy DMT, taking into account the following factors: 1) clinical and MRI disease activity before and during treatment; 2) pharmacokinetics and biological activity of the previous DMT; 3) the potential for resumed disease activity or even rebound, particularly with natalizumab and S1P modulators.
• In the stable patient (clinically and on MRI) who shows no safety or tolerability issues, consider continuing treatment with DMT, taking into account the following patient circumstances: 1) patient characteristics and comorbidities; 2) drug safety profile; 3) family planning; 4) patient values and preferences.

Additional practical issues were addressed in some other topics. For example, when treating patients with natalizumab, and after a period of stability, you can consider switching to a 6-week interval regimen in order to minimise the risk of progressive multifocal leukoencephalopathy (PML). Treatment with high-efficacy DMT including natalizumab can be considered in patients with high disease activity in which a quick therapeutic effect is required, taking into account the risk of PML in John Cunningham virus-positive patients (specifically for natalizumab) as well as the therapeutic lag of the different DMT.

1. Montalban X. Updated recommendations on the treatment of patients with MS. OP184, ECTRIMS 2021 Virtual Congress, 13–15 October.

 

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Posted on 9 December 202125 March 2024