Monday, 10 November 2014

ClinicSpeak: do you have active MS?

Is MS disease activity defined objectively or is up for interpretation? #MSBlog #MSResearch #ClinicSpeak

"In my mind MS disease activity refers to evidence of focal inflammatory activity, i.e. new lesions on MRI or relapses. In contrast the gradual progression, or worsening, of disability that occurs in people with SPMS and PPMS, may or may not occur in the presence of inflammatory activity. Most neurologists require evidence of disease activity in the last 12 months, with some of us accepting a 24 month window if there is no serial MRI support. The corollary of this is if you have had no relapses in the last 24 months and serial MRI studies, covering this period, show no new lesions then your MS is defined as being inactive. This does not mean your MS is necessarily stable, I have already said you could have worsening disability as part of the progressive phase of the disease. If you have so called inactive MS you need to be monitored as inactive MS may reactivate and you could be eligible for treatment."

"In the early 2000’s we used to define disease activity using clinical criteria only; i.e. you needed to have at least 2 documented relapses in the last 2 years to be eligible for DMT.  This meant you needed to be seen by a neurologist so that he/she could examine you to confirm abnormalities on examination compatible with a relapse. The problem with this is that many MSers who didn’t have rapid access to a neurologist would recover from their attack before being assessed so that many of their relapses could not be documented. This was very frustrating for MSers wanting to start a DMT as many neurologists were not prepared to accept historical attacks. I remember seeing many MSers for a second opinion over this issue; a kind of arbitrator to decide who was right the assessing neurologist who would not accept undocumented historical relapses over the patient who knew they had had a relapse. I tended to give patients the benefit of the doubt, particularly if they had MRI evidence to support recent disease activity. How could we deny MSers access to a DMT because they couldn’t be seen in timely way to have their relapse documented in the clinical notes?"

"In 2009 our criteria incorporated MRI into the definition to allow us to treat so called high-risk patients with CIS (clinically-isolated syndromes compatible with demyelination). These criteria required CISers to have 9, or more, T2 lesions on MRI or at least one Gd-enhancing lesions. These MRI criteria were based on the McDonald diagnostic criteria at the time. I personally have never agreed with them. What makes someone with 2 lesions on MRI different from someone with 20 lesions on MRI? It could simply be that the person with 20 lesions has had asymptomatic MS longer than the person with 2 lesions on MRI. If we adopt the principle of treating MS early to prevent damage, why would we want to wait for the CISers to acquire more lesions and hence damage? I take the position that a CISer presenting with a low lesion load is lucky that they presented early with their disease and hence have a greater opportunity to benefit from early treatment. The CISer with a high lesion load unfortunately is the unlucky one. This dilemma is really only a UK problem; outside of the UK almost all neurologists offer CISers DMTs if they have two or more lesions on MRI."

"Now in 2014 NICE (The National Institute for Health and Care Excellence) have given us permission to use Alemtuzumab in adults with active relapsing MS defined clinically or on MRI (see below). This could mean defining activity based on MRI only. I doubt NICE, or the EMA, realise the implications of this ruling. I suspect the OR refers to re-treatment criteria and not the treatment criteria to initiate treatment. It would hard to justify, in the current climate, starting Alemtuzumab in MSers without any recent clinical activity, i.e. relapses. In fact, some of my colleagues are refusing to offer alemtuzumab at all; they have taken the position that the therapy is too risky to justify it use. I have debated their position in the past and think it is unacceptable."

Rapidly-evolving severe MS

"For those of you who have active MS there is a further two subdivisions you need to know about. The first is so called rapidly-evolving severe MS (RES); defined as two disabling attacks in a 12 month period with MRI evidence of activity during this period. This subgroup is eligible for natalizumab and fingolimod."

Highly-active MS

"The other subgroup is so called highly active MS; these are MSers with unchanged or increased relapse rate or ongoing severe relapses compared with the previous year despite treatment with beta interferon, or another so called first-line DMT. The latter definition is part of the NICE final appraisal determination for fingolimod. Please note that this exposes a quirk in the NHS system in that fingolimod can only be prescribed as a second-line therapy. In contrast natalizumab can be used as a first-line treatment in patients who fulfil the definition for having rapidly-evolving severe MS and alemtuzumab for MSers who have active MS defined clinically or on MRI."

"What these definitions don’t address is what we do with SPMSers and PPMSer with worsening disability and no recent relapses (last 2 years) who have new focal and/or Gd-enhancing lesions on their MRI. At present we don’t really have prescribing guidelines that cover these patients. Why not? It is simply because there has been no positive phase 3 studies in this group of MSers to guide our treatments. If you adopt the scientific principle that inflammation is bad for MS you would want to a treatment to tackle this inflammation.  This is why we have used rituximab in the past in a handful or young PPMSers with Gd-enhancing lesions; this is based on the positive subgroup analysis of the phase 2 rituximab in PPMS trial. However, in the UK NHS England have stopped individual funding requests (IFRs) applications to cover this indication; rituximab is simply too expensive for the NHS to be used off license. For this reason we are now offer these patient the option of being treated with subcutaneous cladribine. In the secondary progressive population we still have mitoxantrone on the table."

"The following is a diagram that attempts to explain the classification of active MS based on subsets."

Are you eligible for a DMT?

"Eligibility criteria for DMTs vary across the world and are dependent on licensing rules, national guidelines, payers reimbursement policy and your local MS Team’s prescribing rules. In some parts of the world, for example the US, MS DMTs are simply given a license for treating relapsing MS and it is then left up to the neurologist and the patient to negotiate a treatment. Despite this liberal licensing rule the payers, or insurance companies, set prescribing policy that is usually based on price. The following are NICE's technology appraisals that dictate how we use DMTs in the UK. These appraisals are based on cost-effective models that are designed to ensure the NHS purchases and used DMTs in a cost-effective way."

CoI: multiple


  1. Please can you clarify as to relapses but no new or reactivated lesions on MRI? I'd assume this means the MS is still active?

    1. What is a relapse?

  2. Prof G,

    so what counts as a relapse? Do neurologists want to hear about sensory symptoms that last weeks or months, for instance, with no obvious new MRI activity? In my case there was only one objective relapse which was the initial episode of optic neuritis (described by the ophthalmologist as mild), but with increasing significant fatigue, 2 long lasting urinary issues and nothing on MR. Feels like creeping disability that unchecked may lead to significant problems.

    1. Re: "Do neurologists want to hear about sensory symptoms that last weeks or months, for instance, with no obvious new MRI activity?"

      Yes, we want to hear about these symptoms. Relapses can occur without new MRI lesions. MRI only detects lesions that are 4-5mm or larger. A lesion of less than 1mm can cause a relapse. I have seen many MSers with an INO (internuclear ophthalmoplegia) with no lesion visible in the area of the braistem where a lesion should be.

      If the relapse is not associated with objective signs and the neurologist is not sure an MRI can help him/her make a decision to call something as a relapse or not. Most relapses are associated with MRI activity. Why? Disease activity tends to occur in clusters.

    2. Thanks for your responses, one final question: what are 'objective signs'?

  3. Prof G,

    How long before this disease can be understood? The above is another example of observation / labelling ie if you have this many lesions coming and going you are classified as XX. We have drugs which appear to make the disease inactive eg alemtuzumab. Why is it so difficult to work out what's happening ie what is causing the lesions?

  4. Prof G i need help from you ! I'm from croatia and i have ms symptoms for 10 yrs now , sensory , fatigue , cordination problems at my arm and leg , i did Mr 6 times back from 2009 brain and spine , every time mr was clear exept 2011 which shows high signal on optic nerve, i did vep test, 2004 which was abnormal indicates for optc neuritis , 2009 abnormal, 2010 normal , 2011 abnormal and then again normal, from this year i have dx retrobilateral subclinical optic neuritis i did spinal tap which was negative for antibodies and nmo antibodies negative and oct which shows thinning of rnfl , i have visual disturbance, tinnitus and sensory problems and i don't know what to do anymore ? every neurologist and neurooftamologist told me that we need to wait , i guess waiting for lesions on mdi is not so good option .. so plz if u have some advice id be than full so much , i can send you all my papers ..

    1. Hvala Sasha ali ProfG ne može dati konzultacija na internetu

    2. Sry mouse but it has corelation with this treadh that s why i posted , thnx for response on croatian :))

  5. "In fact, some of my colleagues are refusing to offer alemtuzumab at all; they have taken the position that the therapy is too risky to justify it use. I have debated their position in the past and think it is unacceptable"

    Can they ethically refuse to use this as a treatment for PWMS who meet the criteria given it has now been approved? This really worries me. How do PWMS find out their hospitals / Trust protocol or pathway for DMT's? I'm thinking this may help patients challenge such decisions / individual view points.


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