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LOS ANGELES—Clinicians must engage in an ongoing dialogue with patients with multiple sclerosis (MS) regarding treatment decisions throughout the disease course, according to a new practice guideline from the American Academy of Ne
When considering therapy for a patient with MS, clinicians must take into account the patient’s preferences regarding safety, route of administration, lifestyle, cost, efficacy, common adverse events, and tolerability, the guideline says.
The guideline—which includes 30 recommendations related to starting, switching, and stopping DMTs—“emphasizes that you need to have that discussion with patients, but it does not say for an individual which drug you should take,” said guideline author Ruth Ann Marrie, MD, PhD, Professor of Neurology and Community Health Sciences at the University of Manitoba in Winnipeg. “It provides information about the available therapies so that each clinician–patient dyad can use information specific to that patient to make the best decision for that particular scenario.” 
The guideline was presented at the 70th Annual Meeting of the AAN and published in the April 24 issue of Neurology. It was endorsed by the MS Association of America and the National MS Society.
Therapeutic Advances
Neurologists have “little evidence to decide which drug to use at what time,” said lead guideline author Alexander Rae-Grant, MD, Professor of Neurology at the Cleveland Clinic.
The previous AAN clinical practice guideline on DMTs in MS, published in 2002, reviewed the injectable medications that were approved for MS at the time, such as interferon beta-1b, interferon beta-1a, and glatiramer acetate. Since then, “the treatment landscape has changed considerably … with more than 17 medications currently approved and widely prescribed for treating MS in the United States,” the authors said. “As a result, clinicians and people with MS may now choose from several medications with differing mechanisms of action, risk profiles, and monitoring requirements.” Clinicians must balance the potential therapeutic benefits and risks of a medication and the long-term risk of MS-related morbidity. 
Since the 2002 guideline was published, studies have evaluated the treatment of patients with a first episode of demyelination, Dr. Rae-Grant said. “We now know that treating earlier is better, in terms of reducing the number of new relapses,” which reduces the risk of further brain injury, he said.
For people with highly active MS, clinicians should prescribe alemtuzumab, fingolimod, or natalizumab (Level B recommendation), according to the guideline. In addition, the guideline discusses pregnancy planning, setting realistic treatment expectations, and managing the risk of progressive multifocal leukoencephalopathy (PML). It mentions off-label options and support programs for people who are unable to afford approved DMTs.
Methods and Limitations
To assess evidence for starting, switching, and stopping DMTs for MS and develop relevant recommendations, the guideline authors surveyed peer-reviewed research articles, systematic reviews, and abstracts that they identified searching MEDLINE, CENTRAL, and EMBASE through November 2016. They selected 20 Cochrane reviews and 73 articles for data extraction and rated the studies using the AAN therapeutic classification of evidence scheme. The authors made recommendations using a modified Delphi process.
The guideline largely is based on trial data, which may limit the generalizability of the results to real-world populations, the authors noted. In addition, they anticipate that new research in the rapidly changing field of MS treatment will necessitate updates to the recommendations.
Future studies of DMTs for MS should address gaps in knowledge about long-term outcomes, safety in patients with comorbidities, predictive markers for patient response to treatment, treatment strategies for the initial management of MS, DMT use in pregnant women, and outcomes after stopping DMTs, according to the guideline. Neurologists also need evidence about the effect of DMTs on measures that are important to patients, but are not standard trial outcomes, such as cognition, fatigue, urinary urgency, pain, and visual function.
Navigating a Complex Landscape
The recommendations and systematic review of the evidence “reflect the complexity of MS management in the current treatment era,” said Tanuja Chitnis, MD, of Partners MS Center at Brigham and Women’s Hospital in Boston, and colleagues, in an accompanying editorial. “These statements serve as guidelines for MS patient care; however, they do not replace the clinician–patient relationship on which the most informed decision rests.”
The summary of more than 50 trials “provides a useful scale that can inform clinical decisions,” Dr. Chitnis and colleagues said. Certain drugs that were found to have limited evidence in the systematic review nevertheless “are in common clinical use … based on scientific principles and clinical acumen,” they said. In addition, the guideline reviews the evidence for combination therapies that rarely are used in clinical practice, which “may confuse the casual reader,” the editorialists noted.
“The experienced MS clinician … is needed to help guide patients through this complex landscape,” Dr. Chitnis and colleagues said. “The revised AAN guidelines are a starting point for the use of the multiple treatments now available for MS; however, further work is needed to further refine the choices appropriate for the individual patient.”
—Jake Remaly
Suggested Reading
Chitnis T, Giovannoni G, Trojano M. Complexity of MS management in the current treatment era. Neurology. 2018;90(17):761-762.
Corboy JR, Weinshenker BG, Wingerchuk DM. Comment on 2018 American Academy of Neurology guidelines on disease-modifying therapies in MS. Neurology. 2018 Apr 23 [Epub ahead of print].
Rae-Grant A, Day GS, Marrie RA, et al. Comprehensive systematic review summary: Disease-modifying therapies for adults with multiple sclerosis. Neurology. 2018;90(17):789-800.
Rae-Grant A, Day GS, Marrie RA, et al. Practice guideline recommendations summary: Disease-modifying therapies for adults with multiple sclerosis. Neurology. 2018;90(17):777-788.
LOS ANGELES—Clinicians must engage in an ongoing dialogue with patients with multiple sclerosis (MS) regarding treatment decisions throughout the disease course, according to a new practice guideline from the American Academy of Ne
When considering therapy for a patient with MS, clinicians must take into account the patient’s preferences regarding safety, route of administration, lifestyle, cost, efficacy, common adverse events, and tolerability, the guideline says.
The guideline—which includes 30 recommendations related to starting, switching, and stopping DMTs—“emphasizes that you need to have that discussion with patients, but it does not say for an individual which drug you should take,” said guideline author Ruth Ann Marrie, MD, PhD, Professor of Neurology and Community Health Sciences at the University of Manitoba in Winnipeg. “It provides information about the available therapies so that each clinician–patient dyad can use information specific to that patient to make the best decision for that particular scenario.”
The guideline was presented at the 70th Annual Meeting of the AAN and published in the April 24 issue of Neurology. It was endorsed by the MS Association of America and the National MS Society.
Therapeutic Advances
Neurologists have “little evidence to decide which drug to use at what time,” said lead guideline author Alexander Rae-Grant, MD, Professor of Neurology at the Cleveland Clinic.
The previous AAN clinical practice guideline on DMTs in MS, published in 2002, reviewed the injectable medications that were approved for MS at the time, such as interferon beta-1b, interferon beta-1a, and glatiramer acetate. Since then, “the treatment landscape has changed considerably … with more than 17 medications currently approved and widely prescribed for treating MS in the United States,” the authors said. “As a result, clinicians and people with MS may now choose from several medications with differing mechanisms of action, risk profiles, and monitoring requirements.” Clinicians must balance the potential therapeutic benefits and risks of a medication and the long-term risk of MS-related morbidity.
Since the 2002 guideline was published, studies have evaluated the treatment of patients with a first episode of demyelination, Dr. Rae-Grant said. “We now know that treating earlier is better, in terms of reducing the number of new relapses,” which reduces the risk of further brain injury, he said.
For people with highly active MS, clinicians should prescribe alemtuzumab, fingolimod, or natalizumab (Level B recommendation), according to the guideline. In addition, the guideline discusses pregnancy planning, setting realistic treatment expectations, and managing the risk of progressive multifocal leukoencephalopathy (PML). It mentions off-label options and support programs for people who are unable to afford approved DMTs.
Methods and Limitations
To assess evidence for starting, switching, and stopping DMTs for MS and develop relevant recommendations, the guideline authors surveyed peer-reviewed research articles, systematic reviews, and abstracts that they identified searching MEDLINE, CENTRAL, and EMBASE through November 2016. They selected 20 Cochrane reviews and 73 articles for data extraction and rated the studies using the AAN therapeutic classification of evidence scheme. The authors made recommendations using a modified Delphi process.
The guideline largely is based on trial data, which may limit the generalizability of the results to real-world populations, the authors noted. In addition, they anticipate that new research in the rapidly changing field of MS treatment will necessitate updates to the recommendations.
Future studies of DMTs for MS should address gaps in knowledge about long-term outcomes, safety in patients with comorbidities, predictive markers for patient response to treatment, treatment strategies for the initial management of MS, DMT use in pregnant women, and outcomes after stopping DMTs, according to the guideline. Neurologists also need evidence about the effect of DMTs on measures that are important to patients, but are not standard trial outcomes, such as cognition, fatigue, urinary urgency, pain, and visual function.
Navigating a Complex Landscape
The recommendations and systematic review of the evidence “reflect the complexity of MS management in the current treatment era,” said Tanuja Chitnis, MD, of Partners MS Center at Brigham and Women’s Hospital in Boston, and colleagues, in an accompanying editorial. “These statements serve as guidelines for MS patient care; however, they do not replace the clinician–patient relationship on which the most informed decision rests.”
The summary of more than 50 trials “provides a useful scale that can inform clinical decisions,” Dr. Chitnis and colleagues said. Certain drugs that were found to have limited evidence in the systematic review nevertheless “are in common clinical use … based on scientific principles and clinical acumen,” they said. In addition, the guideline reviews the evidence for combination therapies that rarely are used in clinical practice, which “may confuse the casual reader,” the editorialists noted.
“The experienced MS clinician … is needed to help guide patients through this complex landscape,” Dr. Chitnis and colleagues said. “The revised AAN guidelines are a starting point for the use of the multiple treatments now available for MS; however, further work is needed to further refine the choices appropriate for the individual patient.”
—Jake Remaly
Suggested Reading
Chitnis T, Giovannoni G, Trojano M. Complexity of MS management in the current treatment era. Neurology. 2018;90(17):761-762.
Corboy JR, Weinshenker BG, Wingerchuk DM. Comment on 2018 American Academy of Neurology guidelines on disease-modifying therapies in MS. Neurology. 2018 Apr 23 [Epub ahead of print].
Rae-Grant A, Day GS, Marrie RA, et al. Comprehensive systematic review summary: Disease-modifying therapies for adults with multiple sclerosis. Neurology. 2018;90(17):789-800.
Rae-Grant A, Day GS, Marrie RA, et al. Practice guideline recommendations summary: Disease-modifying therapies for adults with multiple sclerosis. Neurology. 2018;90(17):777-788.
LOS ANGELES—Clinicians must engage in an ongoing dialogue with patients with multiple sclerosis (MS) regarding treatment decisions throughout the disease course, according to a new practice guideline from the American Academy of Ne
When considering therapy for a patient with MS, clinicians must take into account the patient’s preferences regarding safety, route of administration, lifestyle, cost, efficacy, common adverse events, and tolerability, the guideline says.
The guideline—which includes 30 recommendations related to starting, switching, and stopping DMTs—“emphasizes that you need to have that discussion with patients, but it does not say for an individual which drug you should take,” said guideline author Ruth Ann Marrie, MD, PhD, Professor of Neurology and Community Health Sciences at the University of Manitoba in Winnipeg. “It provides information about the available therapies so that each clinician–patient dyad can use information specific to that patient to make the best decision for that particular scenario.”
The guideline was presented at the 70th Annual Meeting of the AAN and published in the April 24 issue of Neurology. It was endorsed by the MS Association of America and the National MS Society.
Therapeutic Advances
Neurologists have “little evidence to decide which drug to use at what time,” said lead guideline author Alexander Rae-Grant, MD, Professor of Neurology at the Cleveland Clinic.
The previous AAN clinical practice guideline on DMTs in MS, published in 2002, reviewed the injectable medications that were approved for MS at the time, such as interferon beta-1b, interferon beta-1a, and glatiramer acetate. Since then, “the treatment landscape has changed considerably … with more than 17 medications currently approved and widely prescribed for treating MS in the United States,” the authors said. “As a result, clinicians and people with MS may now choose from several medications with differing mechanisms of action, risk profiles, and monitoring requirements.” Clinicians must balance the potential therapeutic benefits and risks of a medication and the long-term risk of MS-related morbidity.
Since the 2002 guideline was published, studies have evaluated the treatment of patients with a first episode of demyelination, Dr. Rae-Grant said. “We now know that treating earlier is better, in terms of reducing the number of new relapses,” which reduces the risk of further brain injury, he said.
For people with highly active MS, clinicians should prescribe alemtuzumab, fingolimod, or natalizumab (Level B recommendation), according to the guideline. In addition, the guideline discusses pregnancy planning, setting realistic treatment expectations, and managing the risk of progressive multifocal leukoencephalopathy (PML). It mentions off-label options and support programs for people who are unable to afford approved DMTs.
Methods and Limitations
To assess evidence for starting, switching, and stopping DMTs for MS and develop relevant recommendations, the guideline authors surveyed peer-reviewed research articles, systematic reviews, and abstracts that they identified searching MEDLINE, CENTRAL, and EMBASE through November 2016. They selected 20 Cochrane reviews and 73 articles for data extraction and rated the studies using the AAN therapeutic classification of evidence scheme. The authors made recommendations using a modified Delphi process.
The guideline largely is based on trial data, which may limit the generalizability of the results to real-world populations, the authors noted. In addition, they anticipate that new research in the rapidly changing field of MS treatment will necessitate updates to the recommendations.
Future studies of DMTs for MS should address gaps in knowledge about long-term outcomes, safety in patients with comorbidities, predictive markers for patient response to treatment, treatment strategies for the initial management of MS, DMT use in pregnant women, and outcomes after stopping DMTs, according to the guideline. Neurologists also need evidence about the effect of DMTs on measures that are important to patients, but are not standard trial outcomes, such as cognition, fatigue, urinary urgency, pain, and visual function.
Navigating a Complex Landscape
The recommendations and systematic review of the evidence “reflect the complexity of MS management in the current treatment era,” said Tanuja Chitnis, MD, of Partners MS Center at Brigham and Women’s Hospital in Boston, and colleagues, in an accompanying editorial. “These statements serve as guidelines for MS patient care; however, they do not replace the clinician–patient relationship on which the most informed decision rests.”
The summary of more than 50 trials “provides a useful scale that can inform clinical decisions,” Dr. Chitnis and colleagues said. Certain drugs that were found to have limited evidence in the systematic review nevertheless “are in common clinical use … based on scientific principles and clinical acumen,” they said. In addition, the guideline reviews the evidence for combination therapies that rarely are used in clinical practice, which “may confuse the casual reader,” the editorialists noted.
“The experienced MS clinician … is needed to help guide patients through this complex landscape,” Dr. Chitnis and colleagues said. “The revised AAN guidelines are a starting point for the use of the multiple treatments now available for MS; however, further work is needed to further refine the choices appropriate for the individual patient.”
—Jake Remaly
Suggested Reading
Chitnis T, Giovannoni G, Trojano M. Complexity of MS management in the current treatment era. Neurology. 2018;90(17):761-762.
Corboy JR, Weinshenker BG, Wingerchuk DM. Comment on 2018 American Academy of Neurology guidelines on disease-modifying therapies in MS. Neurology. 2018 Apr 23 [Epub ahead of print].
Rae-Grant A, Day GS, Marrie RA, et al. Comprehensive systematic review summary: Disease-modifying therapies for adults with multiple sclerosis. Neurology. 2018;90(17):789-800.
Rae-Grant A, Day GS, Marrie RA, et al. Practice guideline recommendations summary: Disease-modifying therapies for adults with multiple sclerosis. Neurology. 2018;90(17):777-788.