Approach to Balancing Risk in Multiple Sclerosis Management: a Worldwide Practice Survey
Jodie Roberts1, Aravind Ganesh1, Luca Bartolini2, Tomas Kalincik3
1Department of Clinical Neurosciences, University of Calgary, 2Hasbro Children's Hospital, 3University of Melbourne
Objective:
To explore practice differences in prevailing treatment strategies of multiple sclerosis.
Background:
Available disease-modifying therapies (DMTs) for MS are rapidly expanding; this coincides with debate surrounding DMT selection and treatment strategies. Although escalation approaches have been previously favored to balance safety and efficacy, emerging evidence suggests superior outcomes for MS patients who are exposed to high-efficacy therapies early on. Additionally, there is growing controversy regarding use of gadolinium-based contrast agents in routine monitoring due to risk of gadolinium deposition.
Design/Methods:
We used a worldwide electronic survey launched by the Practice Current section of Neurology® Clinical Practice. Practice-related questions pertained to a case of a 37-year-old female presenting with unilateral optic neuritis alongside non-enhancing lesions in the cerebellum and spinal cord. Respondents were asked to indicate their initial investigations, relapse-management strategy, choice of disease modifying therapy, and plan for follow-up imaging (contrast/non-contrast). Multivariable analysis was precluded by low response numbers.
Results:
We received 153 responses from 42 countries; 32.3% identified as MS specialists. There was a strong preference for intravenous (rather than oral) delivery of high-dose corticosteroids (87.7% vs. 8.0%) and 61.3% indicated they would treat a non-disabling (mild sensory) MS relapse. Given the described clinical scenario, 59.4% felt the patient was at risk of a severe MS course. When asked to select a single initial DMT, 55.8% selected a high-efficacy therapy (67.5% MS specialists vs. 52.4% non-MS specialists). The most selected agents overall were fingolimod (14.7%), natalizumab (15.5%) and dimethyl fumarate (20.9%). Two-thirds of respondents (69.2%) indicated they would request contrast enhanced (vs. non-enhanced) MRI for follow-up imaging (61.9% MS specialists vs. 70.1% non-MS specialists).
Conclusions:
Although there is a slight preference for initiating high-efficacy DMT at the time of initial MS diagnosis, opinions regarding the most appropriate treatment paradigm remain divided.