The American Academy of Neurology (AAN) has issued a new practice guideline regarding the use of disease-modifying therapies (DMTs) for adults with multiple sclerosis (MS). 

The guideline, published in the journal Neurology, provides recommendations on initiating, switching, and discontinuing DMTs relevant to patients with relapsing-remitting MS (RRMS), secondary progressive MS, primary progressive MS (PPMS), and clinically isolated syndromes of demyelination. The recommendations were based on findings from a systematic review and supported by related evidence, principles of care, and inference from evidence. 

The systematic review, which included 20 Cochrane reviews and 73 articles, found that many DMTs proved superior to placebo for patients with RRMS as demonstrated by annualized relapse rates (ARR), new disease activity, and in-study disease progression. In addition, RRMS patients who relapsed while on interferon-β or glatiramer acetate found greater benefit with alemtuzumab vs interferon-β-1a in reducing ARR. The research also showed that patients with PPMS saw greater treatment effect with ocrelizumab vs placebo. 

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A total of 30 recommendations were included in the guideline, with 17 statements addressing DMT initiation, 10 referring to DMT switching when breakthrough disease develops, and 3 regarding DMT discontinuation. The guideline also discusses the risks associated with DMT, including counseling about the possibility of progressive multifocal leukoencephalopathy (PML) in patients taking natalizumab, fingolimod, rituximab, ocrelizumab, and dimethyl fumarate

Some of the major recommendations include:

  • Clinicians should counsel about comorbid disease, adverse health behaviors, and potential interactions of the DMT with concomitant medications when people with MS initiate DMTs
  • After discussing the risks and benefits, clinicians should prescribe DMT to people with a single clinical demyelinating event and 2 or more brain lesions characteristic of MS who decide they want this therapy
  • Clinicians should offer DMTs to people with relapsing forms of MS with recent clinical relapses or MRI activity 
  • Clinicians should prescribe alemtuzumab, fingolimod, or natalizumab for people with MS with highly active MS 
  • Clinicians should offer ocrelizumab to people with PPMS who are likely to benefit from this therapy unless there are risks of treatment that outweigh the benefits
  • People with MS with serious infections potentially linked to their DMT should switch DMTs (does not pertain to PML management in people with MS using DMT) 

The summary of practice guideline recommendations can be found here.

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