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Expert Recommendations on Optimal Multiple Sclerosis Treatment

These "eminence-based" recommendations are useful but still need evidence-based validation.

The multiple sclerosis (MS) research community has yet to codify and validate criteria for treatment response to the licensed drugs (e.g., responder, nonresponder). This regrettable gap in knowledge is due, in part, to insufficient partnering between the pharmaceutical industry and independent investigators. Consequently, MS patients initiate treatment without uniform criteria by which to judge treatment benefit. Patients may continue on treatment indefinitely provided they are "doing well" or "doing better than expected." Others whose conditions are clearly worsening may, rightly or wrongly, decide to remain on treatment in the hope that it is partially effective. Practicing neurologists try to estimate benefit and arbitrarily recommend a change in strategy when patients worsen.

This report represents the consensus opinion of a highly regarded group of Canadian MS specialists who critically reviewed available information about the natural history of MS and the behavior of patients enrolled in clinical trials and then applied these insights to revise previously published guidelines by Bashir and colleagues (Int J MS Care 2002; Suppl 1). In considering whether a patient's treatment should be modified, the authors recommend assessments of relapses, disease progression, and MRI findings; results are categorized as cause for low, medium, or high "level of concern."

Comment: This article contains much measured clinical wisdom. Physicians who test or prescribe MS therapeutic agents should read it with care. However, it is not a systematic review; the authors make no attempt to categorize the level of evidence cited. MS experts may disagree with specific recommendations (e.g., the need to wait 2 years to confirm clinical worsening [as stated in the article text only, not in the relevant table]). Others may believe that dramatic MRI worsening alone should inspire a high level of concern, as Bashir originally suggested. Nonetheless, this work, funded by an educational grant from a major manufacturer of MS drugs, moves us forward another step. As the authors note, this consensus opinion must be validated prospectively to advance the field from "eminence-based" to evidence-based medicine (BMJ 1999; 319:1618).

— John Noseworthy, MD, FRCPC

Dr. Noseworthy is Professor and Chair, Department of Neurology, Mayo Clinic College of Medicine, Rochester, MN.

Published in Journal Watch Neurology October 21, 2004

Citation(s):

Freedman MS et al. for the Canadian MS Working Group. Treatment optimization in multiple sclerosis. Can J Neurol Sci 2004 May; 31:157-68.

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