First European MS treatment guideline. Part one: treatment and monitoring

Given the variety of disease-modifying therapies (DMTs) now available, healthcare professionals must be equipped with up-to-date, evidence-based information to guide treatment-related decision-making. The authors of a new clinical practice guideline for the treatment of people with MS, published in the European Journal of Neurology, aimed to meet this need.1

This is the first article in a two-part series devoted to examining the key messages from this important publication.   

The new guideline, which comprises 21 recommendations spanning the MS treatment pathway, was developed by leading neurologists of the European Committee of Treatment and Research in MS (ECTRIMS) and the European Academy of Neurology (EAN). Importantly, the neurologists used a robust method to formulate their recommendations. They first agreed on ten clinical questions relating to therapeutic interventions and the clinical management of people with MS, which they felt were priorities to cover in the guideline. A systematic review of the literature was conducted for each question and the quality of each piece of evidence was rated according to the risk of bias. The neurologists used these quality-judgements, as well as information on the benefit–risk balance of interventions, to agree recommendations and assign each a level of strength (strong or weak).   

The new guideline recommends that people with active relapsing–remitting MS should be offered early treatment with a DMT; the evidence for this was considered ‘strong’. However, the guideline does not state what it means by ‘early’ treatment. Four of the 21 recommendations in the guideline relate to monitoring treatment responses. MRI scans, alongside clinical measures, are recommended to assess change in disease over time. According to this guideline, an MRI scan of the brain usually performed within six months of starting treatment with a DMT should be compared with one conducted typically 12 months after treatment initiation to monitor an individual’s response to treatment. There are no recommendations on the frequency of ongoing monitoring for this purpose; however, it is recommended that the safety of the chosen therapeutic strategy is monitored by MRI at least once every year.

MS Brain Health research, which will be published later this year, goes further than the new treatment guideline by defining standards for the timing of key events across the MS care pathway. Preliminary research results included timings for treatment initiation and monitoring that MS specialist neurologists agreed are achievable in most healthcare systems.2 For example, there was agreement that a DMT should be offered to a patient with MS within 3 weeks of their becoming eligible for one.2

The publication of the pan-European treatment guideline will be welcomed by those who have been calling for such a resource to help align and disseminate best practice in MS care.3

Look out for the second article in the series in which we will examine what the guideline says about switching treatments.

References

  1. Montalban X, Gold R, Thompson AJ, et al. ECTRIMS/EAN guideline on the pharmacological treatment of people with multiple sclerosis. Eur J Neurol. 2018;25:215–237; doi:10.1111/ene.13536.
  2. Hobart J, Bowen A, Eberhard L, et al. Expert consensus on standards for multiple sclerosis care: preliminary results from a modified Delphi process [poster]. Presented at the 7th Joint ECTRIMS–ACTRIMS meeting, 25–28 October 2017, Paris, France.
  3. Marziniak M, Ghorab K, Kozubski W, et al. Variations in multiple sclerosis practice within Europe – is it time for a new treatment guideline? Mult Scler Relat Disord. 2016;8:35–44; doi: 10.1016/j.msard.2016.04.004.

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