Multiple Sclerosis

Key clinical point: Long-term exposure to fingolimod is associated with lower disability progression in patients with relapsing multiple sclerosis (MS).

Major finding: The high (≥8 years) vs. low (<8 years) exposure groups showed a smaller increase in the mean Expanded Disability Status Scale (+0.55 vs. +1.21) and lower frequencies of disability progression (34.7% vs. 56.1%; P less than .01) and wheelchair use (4.9% vs. 16.9%; P less than .0276) at 10 years.

Study details: ACROSS was a cross-sectional follow-up study of patients with relapsing MS enrolled in a phase 2 proof-of-concept study. Disability outcomes were assessed in patients grouped as per fingolimod exposure: high exposure (n=104) and low exposure (n=71).

Disclosures: The study was funded by Novartis Pharma AG, Basel, Switzerland. Amin Azmon and Davorka Tomic are employees of Novartis. The other authors reported relationships with multiple pharmaceutical companies.

Citation: Derfuss T et al. Mult Scler J Exp Transl Clin. 2020 Mar 30. doi: 10.1177/2055217320907951.

Key clinical point: Long-term exposure to fingolimod is associated with lower disability progression in patients with relapsing multiple sclerosis (MS).

Major finding: The high (≥8 years) vs. low (<8 years) exposure groups showed a smaller increase in the mean Expanded Disability Status Scale (+0.55 vs. +1.21) and lower frequencies of disability progression (34.7% vs. 56.1%; P less than .01) and wheelchair use (4.9% vs. 16.9%; P less than .0276) at 10 years.

Study details: ACROSS was a cross-sectional follow-up study of patients with relapsing MS enrolled in a phase 2 proof-of-concept study. Disability outcomes were assessed in patients grouped as per fingolimod exposure: high exposure (n=104) and low exposure (n=71).

Disclosures: The study was funded by Novartis Pharma AG, Basel, Switzerland. Amin Azmon and Davorka Tomic are employees of Novartis. The other authors reported relationships with multiple pharmaceutical companies.

Citation: Derfuss T et al. Mult Scler J Exp Transl Clin. 2020 Mar 30. doi: 10.1177/2055217320907951.

Key clinical point: Long-term exposure to fingolimod is associated with lower disability progression in patients with relapsing multiple sclerosis (MS).

Major finding: The high (≥8 years) vs. low (<8 years) exposure groups showed a smaller increase in the mean Expanded Disability Status Scale (+0.55 vs. +1.21) and lower frequencies of disability progression (34.7% vs. 56.1%; P less than .01) and wheelchair use (4.9% vs. 16.9%; P less than .0276) at 10 years.

Study details: ACROSS was a cross-sectional follow-up study of patients with relapsing MS enrolled in a phase 2 proof-of-concept study. Disability outcomes were assessed in patients grouped as per fingolimod exposure: high exposure (n=104) and low exposure (n=71).

Disclosures: The study was funded by Novartis Pharma AG, Basel, Switzerland. Amin Azmon and Davorka Tomic are employees of Novartis. The other authors reported relationships with multiple pharmaceutical companies.

Citation: Derfuss T et al. Mult Scler J Exp Transl Clin. 2020 Mar 30. doi: 10.1177/2055217320907951.

Key clinical point: Elevated body mass index (BMI) is independently associated with an accelerated rate of ganglion cell+inner plexiform layer (GCIPL) atrophy in patients with multiple sclerosis (MS).

Major findings: Obese (n=146; BMI, ≥30 kg/m²) vs. normal weight (n=214; BMI, 18.5-24.9 kg/m²) patients showed accelerated rate of GCIPL atrophy (−0.57%/year vs. −0.42%/year; P = .012). Atrophy rates were not significantly different between overweight (n=153; BMI, 25-29.9 kg/m²) and normal weight patients (−0.47%/year vs. −0.42%/year; P = .41). GCIPL atrophy rate accelerated by −0.011% per year with each 1 kg/m² higher BMI (P =.003).

Study details: This observational study included 522 patients with MS from Johns Hopkins MS Center who were followed with retinal imaging for a median of 4.4 years.

Disclosures: The study was funded by the National MS Society, Race to Erase MS, and NIH/NINDS. The presenting author had no disclosures. One coauthor reported receiving support from the Race to Erase MS foundation.

Citation: Filippatou AG et al. Mult Scler. 2020 Apr 16. doi: 10.1177/1352458519900942.

Key clinical point: Elevated body mass index (BMI) is independently associated with an accelerated rate of ganglion cell+inner plexiform layer (GCIPL) atrophy in patients with multiple sclerosis (MS).

Major findings: Obese (n=146; BMI, ≥30 kg/m²) vs. normal weight (n=214; BMI, 18.5-24.9 kg/m²) patients showed accelerated rate of GCIPL atrophy (−0.57%/year vs. −0.42%/year; P = .012). Atrophy rates were not significantly different between overweight (n=153; BMI, 25-29.9 kg/m²) and normal weight patients (−0.47%/year vs. −0.42%/year; P = .41). GCIPL atrophy rate accelerated by −0.011% per year with each 1 kg/m² higher BMI (P =.003).

Study details: This observational study included 522 patients with MS from Johns Hopkins MS Center who were followed with retinal imaging for a median of 4.4 years.

Disclosures: The study was funded by the National MS Society, Race to Erase MS, and NIH/NINDS. The presenting author had no disclosures. One coauthor reported receiving support from the Race to Erase MS foundation.

Citation: Filippatou AG et al. Mult Scler. 2020 Apr 16. doi: 10.1177/1352458519900942.

Key clinical point: Elevated body mass index (BMI) is independently associated with an accelerated rate of ganglion cell+inner plexiform layer (GCIPL) atrophy in patients with multiple sclerosis (MS).

Major findings: Obese (n=146; BMI, ≥30 kg/m²) vs. normal weight (n=214; BMI, 18.5-24.9 kg/m²) patients showed accelerated rate of GCIPL atrophy (−0.57%/year vs. −0.42%/year; P = .012). Atrophy rates were not significantly different between overweight (n=153; BMI, 25-29.9 kg/m²) and normal weight patients (−0.47%/year vs. −0.42%/year; P = .41). GCIPL atrophy rate accelerated by −0.011% per year with each 1 kg/m² higher BMI (P =.003).

Study details: This observational study included 522 patients with MS from Johns Hopkins MS Center who were followed with retinal imaging for a median of 4.4 years.

Disclosures: The study was funded by the National MS Society, Race to Erase MS, and NIH/NINDS. The presenting author had no disclosures. One coauthor reported receiving support from the Race to Erase MS foundation.

Citation: Filippatou AG et al. Mult Scler. 2020 Apr 16. doi: 10.1177/1352458519900942.

Key clinical point: Low fish consumption is associated with an increased risk of developing multiple sclerosis (MS); vitamin D does not mediate this association.

Major finding: Regardless of sun exposure habits, MS risk was higher with low fish consumption, including both lean and fatty fish (odds ratio, 1.2; 95% confidence interval, 1.1-1.4). The mediation analysis revealed that the effect mediated by vitamin D deficiency on this association was very small. A significant interaction was noted between DRB1*15:01 allele and both low sun exposure and low fish consumption.

Study details: The data come from 2 Swedish population-based case-control studies (6,914 patients with MS and 6,590 control participants).

Disclosures: The study was supported by grants from the Swedish Medical Research Council, the Swedish Research Council for Health, Working Life and Welfare, the Swedish Brain Foundation, and the Swedish Society for Medical Research. Dr Olsson reported receiving grants from the Swedish Research Council, the Knut and Alice Wallenberg Foundation, and the Swedish Brain Foundation. Dr Alfredsson reported receiving grants from the Swedish Research Council, the Swedish

Research Council for Health Working Life and Welfare, and the Swedish Brain Foundation.

Citation: Hedström AK et al. Neurol Neuroimmunol Neuroinflamm. 2020 Apr 10. doi: 10.1212/NXI.0000000000000717.

Key clinical point: Low fish consumption is associated with an increased risk of developing multiple sclerosis (MS); vitamin D does not mediate this association.

Major finding: Regardless of sun exposure habits, MS risk was higher with low fish consumption, including both lean and fatty fish (odds ratio, 1.2; 95% confidence interval, 1.1-1.4). The mediation analysis revealed that the effect mediated by vitamin D deficiency on this association was very small. A significant interaction was noted between DRB1*15:01 allele and both low sun exposure and low fish consumption.

Study details: The data come from 2 Swedish population-based case-control studies (6,914 patients with MS and 6,590 control participants).

Disclosures: The study was supported by grants from the Swedish Medical Research Council, the Swedish Research Council for Health, Working Life and Welfare, the Swedish Brain Foundation, and the Swedish Society for Medical Research. Dr Olsson reported receiving grants from the Swedish Research Council, the Knut and Alice Wallenberg Foundation, and the Swedish Brain Foundation. Dr Alfredsson reported receiving grants from the Swedish Research Council, the Swedish

Research Council for Health Working Life and Welfare, and the Swedish Brain Foundation.

Citation: Hedström AK et al. Neurol Neuroimmunol Neuroinflamm. 2020 Apr 10. doi: 10.1212/NXI.0000000000000717.

Key clinical point: Low fish consumption is associated with an increased risk of developing multiple sclerosis (MS); vitamin D does not mediate this association.

Major finding: Regardless of sun exposure habits, MS risk was higher with low fish consumption, including both lean and fatty fish (odds ratio, 1.2; 95% confidence interval, 1.1-1.4). The mediation analysis revealed that the effect mediated by vitamin D deficiency on this association was very small. A significant interaction was noted between DRB1*15:01 allele and both low sun exposure and low fish consumption.

Study details: The data come from 2 Swedish population-based case-control studies (6,914 patients with MS and 6,590 control participants).

Disclosures: The study was supported by grants from the Swedish Medical Research Council, the Swedish Research Council for Health, Working Life and Welfare, the Swedish Brain Foundation, and the Swedish Society for Medical Research. Dr Olsson reported receiving grants from the Swedish Research Council, the Knut and Alice Wallenberg Foundation, and the Swedish Brain Foundation. Dr Alfredsson reported receiving grants from the Swedish Research Council, the Swedish

Research Council for Health Working Life and Welfare, and the Swedish Brain Foundation.

Citation: Hedström AK et al. Neurol Neuroimmunol Neuroinflamm. 2020 Apr 10. doi: 10.1212/NXI.0000000000000717.

Key clinical point: Mercury-containing dental amalgam fillings (AMF) are not associated with the risk of developing multiple sclerosis (MS).

Major finding: The risk of MS with AMF did not differ significantly between patients and control participants (adjusted odds ratio [aOR], 0.823; 95% confidence interval [CI], 0.648-1.046). MS was not associated with AMF irrespective of gender (women: aOR, 0.743; 95% CI, 0.552-1.000; men: aOR, 1.006; 95% CI, 0.670-1.509).

Study details: The data come from a Taiwanese population-based case-control study of 612 participants with MS and 612 matched participants without MS.

Disclosures: No study sponsor was identified. The authors declared no conflicts of interest.

Citation: Tseng CF et al. Int J Environ Res Public Health. 2020 Apr 12. doi: 10.3390/ijerph17082637.

Key clinical point: Mercury-containing dental amalgam fillings (AMF) are not associated with the risk of developing multiple sclerosis (MS).

Major finding: The risk of MS with AMF did not differ significantly between patients and control participants (adjusted odds ratio [aOR], 0.823; 95% confidence interval [CI], 0.648-1.046). MS was not associated with AMF irrespective of gender (women: aOR, 0.743; 95% CI, 0.552-1.000; men: aOR, 1.006; 95% CI, 0.670-1.509).

Study details: The data come from a Taiwanese population-based case-control study of 612 participants with MS and 612 matched participants without MS.

Disclosures: No study sponsor was identified. The authors declared no conflicts of interest.

Citation: Tseng CF et al. Int J Environ Res Public Health. 2020 Apr 12. doi: 10.3390/ijerph17082637.

Key clinical point: Mercury-containing dental amalgam fillings (AMF) are not associated with the risk of developing multiple sclerosis (MS).

Major finding: The risk of MS with AMF did not differ significantly between patients and control participants (adjusted odds ratio [aOR], 0.823; 95% confidence interval [CI], 0.648-1.046). MS was not associated with AMF irrespective of gender (women: aOR, 0.743; 95% CI, 0.552-1.000; men: aOR, 1.006; 95% CI, 0.670-1.509).

Study details: The data come from a Taiwanese population-based case-control study of 612 participants with MS and 612 matched participants without MS.

Disclosures: No study sponsor was identified. The authors declared no conflicts of interest.

Citation: Tseng CF et al. Int J Environ Res Public Health. 2020 Apr 12. doi: 10.3390/ijerph17082637.

The efficacy of the influenza vaccine when given to patients with multiple sclerosis (MS) is similar to that in healthy controls, Jackie Nguyen reported at the virtual annual meeting of the Consortium of Multiple Sclerosis Centers (CMSC). She presented a systematic review and meta-analysis of nine published cohort studies including 417 MS patients and more than 500 healthy controls, all of whom received inactivated seasonal influenza vaccine.

The impetus for this project was a recognition that the great majority of the research on the impact of influenza vaccine in patients with MS has focused on safety and MS relapse rates. In contrast, the nine studies included in the meta-analysis contained data on influenza vaccine efficacy as reflected in the ability to mount an adequate immune response. This was defined in standard fashion either by seroconversion, which required at least a fourfold increase in antibody titers following vaccination, or seroprotection, with a postvaccination antihemagglutination immunoglobulin G titer of at least 40. The analysis included patients with MS irrespective of disease duration or severity or treatment regimen, noted Ms. Nguyen, a third-year medical student at Nova Southeastern University College of Allopathic Medicine in Davie, Fla.

The researchers found that there was no significant difference between patients with MS and healthy controls in the rates of an adequate immune response for influenza H1N1, H3N2, or influenza B virus. “The vaccine should thus continue to be recommended for MS patients, as the data shows it to be efficacious,” she said.

Her conclusion is consistent with guidance provided in the American Academy of Neurology’s 2019 practice guideline update on immunization in MS, highlighted elsewhere at CMSC 2020 in a presentation by Marijean Buhse, PhD, of Stony Brook University in New York.

The guideline, updated for the first time in 17 years, states that all MS patients should be advised to receive influenza vaccine annually: “With known risks of exacerbation and other morbidity with influenza infection and no identified risks of exacerbation with influenza vaccines, benefits of influenza vaccination outweigh the risks in most scenarios. The exception involves the relatively few MS patients having a specific contraindication to the influenza vaccine, such as a previous severe reaction, noted Dr. Buhse, who wasn’t involved in developing the evidence-based guidelines.

The available evidence indicates that some but not all disease-modifying therapies for MS reduce the effectiveness of vaccination against influenza.

According to the guideline, “it is possible” that persons with MS being treated with glatiramer acetate have a reduced likelihood of seroprotection from influenza vaccine, a conclusion the guidelines committee drew with “low confidence in the evidence.” Further, the guideline states that “it is probable” MS patients on fingolimod have a lower likelihood of obtaining seroprotection from influenza vaccine than patients not on the drug, with moderate confidence in the evidence. Also, it is deemed probable that patients with MS who are taking mitoxantrone have a reduced likelihood of response to influenza vaccination, compared with healthy controls. But it is probable that patients with MS who are receiving interferon-beta have no diminution in the likelihood of seroprotection. According to the guideline, there is insufficient evidence to say whether patients with MS who are on natalizumab, teriflunomide, or methotrexate have a diminished response to influenza vaccination.

Dr. Buhse noted that rituximab is off-label therapy for MS, so there are no data available regarding the likelihood of seroprotection in response to influenza vaccination in that setting. However, rituximab profoundly decreases the immunogenicity of influenza and pneumococcal vaccines in rheumatoid arthritis patients. It is therefore recommended that inactivated influenza vaccine be given to patients with MS at least 2 weeks prior to starting rituximab or 6 months after the last dose in order to optimize the humoral results. Ms. Nguyen reported having no financial conflicts regarding her presentation. Dr. Buhse reported having received honoraria from Genzyme and Biogen.

[email protected]

The efficacy of the influenza vaccine when given to patients with multiple sclerosis (MS) is similar to that in healthy controls, Jackie Nguyen reported at the virtual annual meeting of the Consortium of Multiple Sclerosis Centers (CMSC). She presented a systematic review and meta-analysis of nine published cohort studies including 417 MS patients and more than 500 healthy controls, all of whom received inactivated seasonal influenza vaccine.

The impetus for this project was a recognition that the great majority of the research on the impact of influenza vaccine in patients with MS has focused on safety and MS relapse rates. In contrast, the nine studies included in the meta-analysis contained data on influenza vaccine efficacy as reflected in the ability to mount an adequate immune response. This was defined in standard fashion either by seroconversion, which required at least a fourfold increase in antibody titers following vaccination, or seroprotection, with a postvaccination antihemagglutination immunoglobulin G titer of at least 40. The analysis included patients with MS irrespective of disease duration or severity or treatment regimen, noted Ms. Nguyen, a third-year medical student at Nova Southeastern University College of Allopathic Medicine in Davie, Fla.

The researchers found that there was no significant difference between patients with MS and healthy controls in the rates of an adequate immune response for influenza H1N1, H3N2, or influenza B virus. “The vaccine should thus continue to be recommended for MS patients, as the data shows it to be efficacious,” she said.

Her conclusion is consistent with guidance provided in the American Academy of Neurology’s 2019 practice guideline update on immunization in MS, highlighted elsewhere at CMSC 2020 in a presentation by Marijean Buhse, PhD, of Stony Brook University in New York.

The guideline, updated for the first time in 17 years, states that all MS patients should be advised to receive influenza vaccine annually: “With known risks of exacerbation and other morbidity with influenza infection and no identified risks of exacerbation with influenza vaccines, benefits of influenza vaccination outweigh the risks in most scenarios. The exception involves the relatively few MS patients having a specific contraindication to the influenza vaccine, such as a previous severe reaction, noted Dr. Buhse, who wasn’t involved in developing the evidence-based guidelines.

The available evidence indicates that some but not all disease-modifying therapies for MS reduce the effectiveness of vaccination against influenza.

According to the guideline, “it is possible” that persons with MS being treated with glatiramer acetate have a reduced likelihood of seroprotection from influenza vaccine, a conclusion the guidelines committee drew with “low confidence in the evidence.” Further, the guideline states that “it is probable” MS patients on fingolimod have a lower likelihood of obtaining seroprotection from influenza vaccine than patients not on the drug, with moderate confidence in the evidence. Also, it is deemed probable that patients with MS who are taking mitoxantrone have a reduced likelihood of response to influenza vaccination, compared with healthy controls. But it is probable that patients with MS who are receiving interferon-beta have no diminution in the likelihood of seroprotection. According to the guideline, there is insufficient evidence to say whether patients with MS who are on natalizumab, teriflunomide, or methotrexate have a diminished response to influenza vaccination.

Dr. Buhse noted that rituximab is off-label therapy for MS, so there are no data available regarding the likelihood of seroprotection in response to influenza vaccination in that setting. However, rituximab profoundly decreases the immunogenicity of influenza and pneumococcal vaccines in rheumatoid arthritis patients. It is therefore recommended that inactivated influenza vaccine be given to patients with MS at least 2 weeks prior to starting rituximab or 6 months after the last dose in order to optimize the humoral results. Ms. Nguyen reported having no financial conflicts regarding her presentation. Dr. Buhse reported having received honoraria from Genzyme and Biogen.

[email protected]

The efficacy of the influenza vaccine when given to patients with multiple sclerosis (MS) is similar to that in healthy controls, Jackie Nguyen reported at the virtual annual meeting of the Consortium of Multiple Sclerosis Centers (CMSC). She presented a systematic review and meta-analysis of nine published cohort studies including 417 MS patients and more than 500 healthy controls, all of whom received inactivated seasonal influenza vaccine.

The impetus for this project was a recognition that the great majority of the research on the impact of influenza vaccine in patients with MS has focused on safety and MS relapse rates. In contrast, the nine studies included in the meta-analysis contained data on influenza vaccine efficacy as reflected in the ability to mount an adequate immune response. This was defined in standard fashion either by seroconversion, which required at least a fourfold increase in antibody titers following vaccination, or seroprotection, with a postvaccination antihemagglutination immunoglobulin G titer of at least 40. The analysis included patients with MS irrespective of disease duration or severity or treatment regimen, noted Ms. Nguyen, a third-year medical student at Nova Southeastern University College of Allopathic Medicine in Davie, Fla.

The researchers found that there was no significant difference between patients with MS and healthy controls in the rates of an adequate immune response for influenza H1N1, H3N2, or influenza B virus. “The vaccine should thus continue to be recommended for MS patients, as the data shows it to be efficacious,” she said.

Her conclusion is consistent with guidance provided in the American Academy of Neurology’s 2019 practice guideline update on immunization in MS, highlighted elsewhere at CMSC 2020 in a presentation by Marijean Buhse, PhD, of Stony Brook University in New York.

The guideline, updated for the first time in 17 years, states that all MS patients should be advised to receive influenza vaccine annually: “With known risks of exacerbation and other morbidity with influenza infection and no identified risks of exacerbation with influenza vaccines, benefits of influenza vaccination outweigh the risks in most scenarios. The exception involves the relatively few MS patients having a specific contraindication to the influenza vaccine, such as a previous severe reaction, noted Dr. Buhse, who wasn’t involved in developing the evidence-based guidelines.

The available evidence indicates that some but not all disease-modifying therapies for MS reduce the effectiveness of vaccination against influenza.

According to the guideline, “it is possible” that persons with MS being treated with glatiramer acetate have a reduced likelihood of seroprotection from influenza vaccine, a conclusion the guidelines committee drew with “low confidence in the evidence.” Further, the guideline states that “it is probable” MS patients on fingolimod have a lower likelihood of obtaining seroprotection from influenza vaccine than patients not on the drug, with moderate confidence in the evidence. Also, it is deemed probable that patients with MS who are taking mitoxantrone have a reduced likelihood of response to influenza vaccination, compared with healthy controls. But it is probable that patients with MS who are receiving interferon-beta have no diminution in the likelihood of seroprotection. According to the guideline, there is insufficient evidence to say whether patients with MS who are on natalizumab, teriflunomide, or methotrexate have a diminished response to influenza vaccination.

Dr. Buhse noted that rituximab is off-label therapy for MS, so there are no data available regarding the likelihood of seroprotection in response to influenza vaccination in that setting. However, rituximab profoundly decreases the immunogenicity of influenza and pneumococcal vaccines in rheumatoid arthritis patients. It is therefore recommended that inactivated influenza vaccine be given to patients with MS at least 2 weeks prior to starting rituximab or 6 months after the last dose in order to optimize the humoral results. Ms. Nguyen reported having no financial conflicts regarding her presentation. Dr. Buhse reported having received honoraria from Genzyme and Biogen.

[email protected]

Key clinical point: Periconceptional rituximab is a highly effective and safe treatment for women with suboptimally controlled multiple sclerosis (MS).

Major finding: Among 38 live births, 3 deliveries were preterm (including 1 set of twins), 1 baby was admitted for perinatal ischemic stroke, and 1 twin died after 6 days from an intraventricular hemorrhage. Fifteen women reported at least one first-trimester miscarriage, of whom 8 had a history of infertility. No stillbirths, chorioamnionitis, or major malformations were recorded. Only 2 women experienced relapses, one during pregnancy and the other postpartum.

Study details: The data come from a study of 55 women with MS (74 pregnancies) treated with at least 1 dose of rituximab infusion before conception.

Disclosures: This study was supported in part by the Patient-Centered Outcomes Research Institute.

Some of the investigators reported receiving research grants from multiple pharmaceutical companies.

Citation: Smith JB et al. Neurol Neuroimmunol Neuroinflamm. 2020 May 01. doi: 10.1212/NXI.0000000000000734.

Key clinical point: Periconceptional rituximab is a highly effective and safe treatment for women with suboptimally controlled multiple sclerosis (MS).

Major finding: Among 38 live births, 3 deliveries were preterm (including 1 set of twins), 1 baby was admitted for perinatal ischemic stroke, and 1 twin died after 6 days from an intraventricular hemorrhage. Fifteen women reported at least one first-trimester miscarriage, of whom 8 had a history of infertility. No stillbirths, chorioamnionitis, or major malformations were recorded. Only 2 women experienced relapses, one during pregnancy and the other postpartum.

Study details: The data come from a study of 55 women with MS (74 pregnancies) treated with at least 1 dose of rituximab infusion before conception.

Disclosures: This study was supported in part by the Patient-Centered Outcomes Research Institute.

Some of the investigators reported receiving research grants from multiple pharmaceutical companies.

Citation: Smith JB et al. Neurol Neuroimmunol Neuroinflamm. 2020 May 01. doi: 10.1212/NXI.0000000000000734.

Key clinical point: Periconceptional rituximab is a highly effective and safe treatment for women with suboptimally controlled multiple sclerosis (MS).

Major finding: Among 38 live births, 3 deliveries were preterm (including 1 set of twins), 1 baby was admitted for perinatal ischemic stroke, and 1 twin died after 6 days from an intraventricular hemorrhage. Fifteen women reported at least one first-trimester miscarriage, of whom 8 had a history of infertility. No stillbirths, chorioamnionitis, or major malformations were recorded. Only 2 women experienced relapses, one during pregnancy and the other postpartum.

Study details: The data come from a study of 55 women with MS (74 pregnancies) treated with at least 1 dose of rituximab infusion before conception.

Disclosures: This study was supported in part by the Patient-Centered Outcomes Research Institute.

Some of the investigators reported receiving research grants from multiple pharmaceutical companies.

Citation: Smith JB et al. Neurol Neuroimmunol Neuroinflamm. 2020 May 01. doi: 10.1212/NXI.0000000000000734.

Key clinical point: Patients with multiple sclerosis (MS) are at an increased risk of cardiovascular and cerebrovascular diseases that traditional risk factors do not fully explain.

Major finding: Compared with people without MS, patients with MS had increased risks for coronary syndrome (hazard ratio [HR], 1.28), cerebrovascular disease (HR, 1.59), any macrovascular disease (HR, 1.32), all-cause mortality (HR, 3.46), and cardiovascular disease mortality (HR, 1.47).

Study details: This population-based, retrospective matched cohort study conducted in England included 12,251 patients with MS and 72,572 people without MS.

Disclosures: The presenting author had no disclosures. Two coauthors received research funding/support from various organizations.

Citation: Palladino R et al. JAMA Neurol. 2020 May 04. doi: 10.1001/jamaneurol.2020.0664. 

Key clinical point: Patients with multiple sclerosis (MS) are at an increased risk of cardiovascular and cerebrovascular diseases that traditional risk factors do not fully explain.

Major finding: Compared with people without MS, patients with MS had increased risks for coronary syndrome (hazard ratio [HR], 1.28), cerebrovascular disease (HR, 1.59), any macrovascular disease (HR, 1.32), all-cause mortality (HR, 3.46), and cardiovascular disease mortality (HR, 1.47).

Study details: This population-based, retrospective matched cohort study conducted in England included 12,251 patients with MS and 72,572 people without MS.

Disclosures: The presenting author had no disclosures. Two coauthors received research funding/support from various organizations.

Citation: Palladino R et al. JAMA Neurol. 2020 May 04. doi: 10.1001/jamaneurol.2020.0664. 

Key clinical point: Patients with multiple sclerosis (MS) are at an increased risk of cardiovascular and cerebrovascular diseases that traditional risk factors do not fully explain.

Major finding: Compared with people without MS, patients with MS had increased risks for coronary syndrome (hazard ratio [HR], 1.28), cerebrovascular disease (HR, 1.59), any macrovascular disease (HR, 1.32), all-cause mortality (HR, 3.46), and cardiovascular disease mortality (HR, 1.47).

Study details: This population-based, retrospective matched cohort study conducted in England included 12,251 patients with MS and 72,572 people without MS.

Disclosures: The presenting author had no disclosures. Two coauthors received research funding/support from various organizations.

Citation: Palladino R et al. JAMA Neurol. 2020 May 04. doi: 10.1001/jamaneurol.2020.0664. 

Key clinical point: Relapse rates are comparable for patients with relapsing-remitting multiple sclerosis (RRMS) treated with fingolimod, dimethyl fumarate, or teriflunomide.

Major finding: After 2 years of treatment initiation, the estimated mean annualized relapse rates were 0.13 (95% confidence interval, 0.04-0.43) for fingolimod, 0.09 (95% confidence interval, 0.03-0.26) for dimethyl fumarate, and 0.11 (95% confidence interval, 0.04-0.35) for teriflunomide.

Study details: The study used inverse probability weighing to compare the efficacy of fingolimod (n=295), dimethyl fumarate (n=227), and teriflunomide (n=107) treatment for at least 24 months in patients with RRMS identified from the Austrian MS Treatment Registry.

Disclosures: The study was funded by Kepler Universitätsklinikum Linz. S Kalcher and E Kvas declared no conflicts of interest. Other authors reported ties with one or more pharmaceutical companies.

Citation: Guger M et al. J Neurol. 2020 Apr 3. doi: 10.1007/s00415-020-09811-6.

Key clinical point: Relapse rates are comparable for patients with relapsing-remitting multiple sclerosis (RRMS) treated with fingolimod, dimethyl fumarate, or teriflunomide.

Major finding: After 2 years of treatment initiation, the estimated mean annualized relapse rates were 0.13 (95% confidence interval, 0.04-0.43) for fingolimod, 0.09 (95% confidence interval, 0.03-0.26) for dimethyl fumarate, and 0.11 (95% confidence interval, 0.04-0.35) for teriflunomide.

Study details: The study used inverse probability weighing to compare the efficacy of fingolimod (n=295), dimethyl fumarate (n=227), and teriflunomide (n=107) treatment for at least 24 months in patients with RRMS identified from the Austrian MS Treatment Registry.

Disclosures: The study was funded by Kepler Universitätsklinikum Linz. S Kalcher and E Kvas declared no conflicts of interest. Other authors reported ties with one or more pharmaceutical companies.

Citation: Guger M et al. J Neurol. 2020 Apr 3. doi: 10.1007/s00415-020-09811-6.

Key clinical point: Relapse rates are comparable for patients with relapsing-remitting multiple sclerosis (RRMS) treated with fingolimod, dimethyl fumarate, or teriflunomide.

Major finding: After 2 years of treatment initiation, the estimated mean annualized relapse rates were 0.13 (95% confidence interval, 0.04-0.43) for fingolimod, 0.09 (95% confidence interval, 0.03-0.26) for dimethyl fumarate, and 0.11 (95% confidence interval, 0.04-0.35) for teriflunomide.

Study details: The study used inverse probability weighing to compare the efficacy of fingolimod (n=295), dimethyl fumarate (n=227), and teriflunomide (n=107) treatment for at least 24 months in patients with RRMS identified from the Austrian MS Treatment Registry.

Disclosures: The study was funded by Kepler Universitätsklinikum Linz. S Kalcher and E Kvas declared no conflicts of interest. Other authors reported ties with one or more pharmaceutical companies.

Citation: Guger M et al. J Neurol. 2020 Apr 3. doi: 10.1007/s00415-020-09811-6.

Key clinical point: The correlation of muscle strength in the lower extremity and trunk with walking performance is stronger in patients with multiple sclerosis (MS) having mild disability than in those having moderate disability.

Major finding: The mild vs. moderate disability group exhibited stronger Pearson correlations of muscle strength to Timed 25-Foot Walk (P less than .001) and 6-minute walk test (P less than .001). For Timed 25-Foot Walk, ankle dorsiflexion (P = .002), knee extension (P = .001), and hip abduction (P = .046) had significantly higher beta coefficients in the mild than moderate disability group.

Study details: A cross-sectional study analyzed data of patients with MS having mild disability (Expanded Disability Status scale [EDSS], 0-3.5; n=36) and moderate disability (EDSS, 4.0-5.5; n=36).

Disclosures: Dr J Kittelson received consulting fees for work on advisory and steering committees for CPC Clinical Research, Bayer Healthcare, Janssen Pharmaceuticals, and Pfizer and for work on data and safety monitoring committees from the Cystic Fibrosis Foundation Therapeutics, Novo Nordisk, Pfizer, Genentech, and BioMarin Pharmaceuticals. Dr MM Mañago, J Callesen, U Dalgas, and M Schenkman declared no conflicts of interest. The study did not receive any external funding.

Citation: Mañago MM et al. Mult Scler Relat Disord. 2020 Mar 13. doi: 10.1016/j.msard.2020.102052

Key clinical point: The correlation of muscle strength in the lower extremity and trunk with walking performance is stronger in patients with multiple sclerosis (MS) having mild disability than in those having moderate disability.

Major finding: The mild vs. moderate disability group exhibited stronger Pearson correlations of muscle strength to Timed 25-Foot Walk (P less than .001) and 6-minute walk test (P less than .001). For Timed 25-Foot Walk, ankle dorsiflexion (P = .002), knee extension (P = .001), and hip abduction (P = .046) had significantly higher beta coefficients in the mild than moderate disability group.

Study details: A cross-sectional study analyzed data of patients with MS having mild disability (Expanded Disability Status scale [EDSS], 0-3.5; n=36) and moderate disability (EDSS, 4.0-5.5; n=36).

Disclosures: Dr J Kittelson received consulting fees for work on advisory and steering committees for CPC Clinical Research, Bayer Healthcare, Janssen Pharmaceuticals, and Pfizer and for work on data and safety monitoring committees from the Cystic Fibrosis Foundation Therapeutics, Novo Nordisk, Pfizer, Genentech, and BioMarin Pharmaceuticals. Dr MM Mañago, J Callesen, U Dalgas, and M Schenkman declared no conflicts of interest. The study did not receive any external funding.

Citation: Mañago MM et al. Mult Scler Relat Disord. 2020 Mar 13. doi: 10.1016/j.msard.2020.102052

Key clinical point: The correlation of muscle strength in the lower extremity and trunk with walking performance is stronger in patients with multiple sclerosis (MS) having mild disability than in those having moderate disability.

Major finding: The mild vs. moderate disability group exhibited stronger Pearson correlations of muscle strength to Timed 25-Foot Walk (P less than .001) and 6-minute walk test (P less than .001). For Timed 25-Foot Walk, ankle dorsiflexion (P = .002), knee extension (P = .001), and hip abduction (P = .046) had significantly higher beta coefficients in the mild than moderate disability group.

Study details: A cross-sectional study analyzed data of patients with MS having mild disability (Expanded Disability Status scale [EDSS], 0-3.5; n=36) and moderate disability (EDSS, 4.0-5.5; n=36).

Disclosures: Dr J Kittelson received consulting fees for work on advisory and steering committees for CPC Clinical Research, Bayer Healthcare, Janssen Pharmaceuticals, and Pfizer and for work on data and safety monitoring committees from the Cystic Fibrosis Foundation Therapeutics, Novo Nordisk, Pfizer, Genentech, and BioMarin Pharmaceuticals. Dr MM Mañago, J Callesen, U Dalgas, and M Schenkman declared no conflicts of interest. The study did not receive any external funding.

Citation: Mañago MM et al. Mult Scler Relat Disord. 2020 Mar 13. doi: 10.1016/j.msard.2020.102052

Proposed updates to guidelines for magnetic resonance imaging in patients with multiple sclerosis (MS) are in the works to make the Consortium of Multiple Sclerosis Centers protocol and other international guidelines more similar, with the hope that internationally accepted consensus guidelines will improve lagging conformity with the recommendations.

“We’ve always envisioned the guidelines as being international, but now we have harmony with the groups, so this is truly a global protocol,” Anthony Traboulsee, MD, a professor of neurology and director of the MS clinic and neuromyelitis optica clinic at the University of British Columbia in Vancouver, said in presenting the proposed updates during the virtual meeting of the CMSC.

The updates reflect the input of an international expert panel convened by the CMSC in October 2019, made up of neurologists, radiologists, magnetic resonance technologists, and imaging scientists with expertise in MS. Attendees represented groups including the European-based Magnetic Resonance Imaging in MS (MAGNIMS), North American Imaging in Multiple Sclerosis Cooperative, National MS Society, Multiple Sclerosis Association of America, MRI manufacturers, and commercial image analysis.
 

Standardizing scans

While the mission was to review and update the current guidelines, an important overriding objective was to boost universal acceptance and improve the utilization of the protocol, which research shows is surprisingly low. According to one poster presented at the meeting, a real-world MRI dataset of 1,233 sessions showed only 8% satisfied criteria for the T1 sequence outlined in the 2018 guidelines, and only 7% satisfied criteria for the T2 sequence. “In a real-world MRI dataset of patients with MS, the conformance to the CMSC brain MRI guidelines was extremely low,” concluded the authors, who were with Icometrix, in Chicago and Belgium.

David Li, MD, also of the University of British Columbia and cochair of the MRI guideline committee, said the nonconformity has important implications. “Nonstandardized scans, with inconsistent slice thickness and gaps, nonstandardized slice acquisition (not in the subcallosal plane), and incomplete brain coverage, all contribute to scans that are difficult to compare,” he said. Those factors, “allow for assessment of new lesions and lesion activity that are invaluable for diagnosis as well as determining the effectiveness of therapy or the need for initiating/changing therapy.”

Dr. Traboulsee said the lack of adherence to guidelines may simply have to do with a mistaken perception of complexity. “Part of the challenge is MRI centers don’t realize how easy it is to implement these guidelines,” he said in presenting the proposed updates.

Dr. Traboulsee noted that the CMSC has been working with manufacturers to try to incorporate the protocol into the scanners “so that it’s just a button to press” for the MRI. “I think that will get us over a major hurdle of adaptation,” Dr. Traboulsee said. “Most radiologists said once they started using it they were really happy with it. They found they were using it beyond MS for other basic neurologic imaging, so just raising awareness and making things more of a one-step process for individuals to use will be helpful,” he said.
 

Repositioning consistency is key

Among key suggestions that the expert panel proposed for guideline updates include the use of the subcallosal plane for consistent repositioning, which should allow for more accuracy and consistency in the identification of lesions in MS, Dr. Traboulsee said. “A major change reflecting improvements in MRI technology is the ability to acquire high-resolution 3-D images and that’s particularly helpful with fluid attenuation inversion recovery (FLAIR) sequences, which is what we do to identify lesions,” he explained. “The repositioning along the subcallosal line is important because it allows us to easily compare studies over time. It takes very little time but allows us to prepare studies over time much more easily,” he said.

Central vein sign

Another update is the establishment of a new category of optimum plus sequences allowing for the monitoring of brain atrophy and identifying lesions with a central vein sign, which has gained high interest as a marker on 3T MRI of demyelinating plaques in MS. As described in recent research, the central vein sign shows high accuracy in differentiating between MS and non-MS lesions.

“Many people have a few white spots on neuroimaging, but with MRI so much more available around the world, many of them are being misdiagnosed with MS,” Dr. Traboulsee said. “But the central vein sign, using a very simple MRI technique, can identify lesions with a vein in the center that (distinguishes them as) MS lesions.”

Though the process is still several years from routine clinical use, the proposed update would better implement susceptibility weighted imaging, which has traditionally been used for functional MRI.
 

PML Surveillance

The updates also include recommendations to help in the detection of the rare but potentially serious complication of some disease-modifying therapies of progressive multifocal leukoencephalopathy (PML). “We need a very quick and comprehensive way to monitor patients for PML before symptoms develop,” Dr. Traboulsee said. “The sequences we recommended were based on expert opinion of people who have worked quite a bit with PML in MS, and if one wants to survey for PML it’s only about a 10-minute scan.”

International protocol

Corey Ford, MD, a professor of neurology and director of the MS Specialty Clinic at the University of New Mexico Health Sciences Center in Albuquerque, commented that, with imaging playing such an important role in MS, the lack of adherence to the protocol can be a significant hindrance. “MRI is the most important imaging tool we have in the diagnosing and management of MS, but ... it’s quite amazing how different the sequences that are used can be when imaging centers are asked to image someone with a diagnosis of MS, so it’s a problem,” he said.

Dr. Ford speculated that part of the problem is simply inertia at some imaging centers. “Practices will have been programmed into their protocol for a long time, so when a patient comes in for imaging regarding MS, they may [turn to] their typical sequence,” he said. “There is an inertial barrier to upgrading that sequence, which can involve testing it out on the machine, training the techs to do it that way, and interpreting it for the physician clients who requested the imaging.”

In addition, there is a lack of exposure of MS imaging guidelines in the radiology literature, Dr. Ford added. “Maybe it’s a matter of giving more presentations at meetings that include radiologists, or getting the information out through the manufacturers. I think at the end of the day it could be a combination of all of those things,” he said.

However, the CMSC collaboration could make a big difference, Dr. Ford noted. “This is where the international protocol could be important in terms of making all of this happen,” he said. “What we’re seeing is the confluence of representatives of the U.S. and European centers hash out a consensus, and if it’s international, I think that adds a lot of weight to an eventual implementation on a wider basis.”

“I think the group has done a stellar job, and we should not try to be too focused on adding everyone’s little tweak,” he noted. “If we can get a good baseline foundational imaging sequence that can be implemented worldwide, we would be much better off.”

The CMSC updated imaging guidelines are expected to be published in coming months. The most recent previous updates are available online.

Dr. Traboulsee disclosed relationships with Biogen, Chugai, Roche, Sanofi, and Teva. Dr. Ford and Dr. Li have disclosed no relevant financial relationships.

A version of this article originally appeared on Medscape.com.

Proposed updates to guidelines for magnetic resonance imaging in patients with multiple sclerosis (MS) are in the works to make the Consortium of Multiple Sclerosis Centers protocol and other international guidelines more similar, with the hope that internationally accepted consensus guidelines will improve lagging conformity with the recommendations.

“We’ve always envisioned the guidelines as being international, but now we have harmony with the groups, so this is truly a global protocol,” Anthony Traboulsee, MD, a professor of neurology and director of the MS clinic and neuromyelitis optica clinic at the University of British Columbia in Vancouver, said in presenting the proposed updates during the virtual meeting of the CMSC.

The updates reflect the input of an international expert panel convened by the CMSC in October 2019, made up of neurologists, radiologists, magnetic resonance technologists, and imaging scientists with expertise in MS. Attendees represented groups including the European-based Magnetic Resonance Imaging in MS (MAGNIMS), North American Imaging in Multiple Sclerosis Cooperative, National MS Society, Multiple Sclerosis Association of America, MRI manufacturers, and commercial image analysis.
 

Standardizing scans

While the mission was to review and update the current guidelines, an important overriding objective was to boost universal acceptance and improve the utilization of the protocol, which research shows is surprisingly low. According to one poster presented at the meeting, a real-world MRI dataset of 1,233 sessions showed only 8% satisfied criteria for the T1 sequence outlined in the 2018 guidelines, and only 7% satisfied criteria for the T2 sequence. “In a real-world MRI dataset of patients with MS, the conformance to the CMSC brain MRI guidelines was extremely low,” concluded the authors, who were with Icometrix, in Chicago and Belgium.

David Li, MD, also of the University of British Columbia and cochair of the MRI guideline committee, said the nonconformity has important implications. “Nonstandardized scans, with inconsistent slice thickness and gaps, nonstandardized slice acquisition (not in the subcallosal plane), and incomplete brain coverage, all contribute to scans that are difficult to compare,” he said. Those factors, “allow for assessment of new lesions and lesion activity that are invaluable for diagnosis as well as determining the effectiveness of therapy or the need for initiating/changing therapy.”

Dr. Traboulsee said the lack of adherence to guidelines may simply have to do with a mistaken perception of complexity. “Part of the challenge is MRI centers don’t realize how easy it is to implement these guidelines,” he said in presenting the proposed updates.

Dr. Traboulsee noted that the CMSC has been working with manufacturers to try to incorporate the protocol into the scanners “so that it’s just a button to press” for the MRI. “I think that will get us over a major hurdle of adaptation,” Dr. Traboulsee said. “Most radiologists said once they started using it they were really happy with it. They found they were using it beyond MS for other basic neurologic imaging, so just raising awareness and making things more of a one-step process for individuals to use will be helpful,” he said.
 

Repositioning consistency is key

Among key suggestions that the expert panel proposed for guideline updates include the use of the subcallosal plane for consistent repositioning, which should allow for more accuracy and consistency in the identification of lesions in MS, Dr. Traboulsee said. “A major change reflecting improvements in MRI technology is the ability to acquire high-resolution 3-D images and that’s particularly helpful with fluid attenuation inversion recovery (FLAIR) sequences, which is what we do to identify lesions,” he explained. “The repositioning along the subcallosal line is important because it allows us to easily compare studies over time. It takes very little time but allows us to prepare studies over time much more easily,” he said.

Central vein sign

Another update is the establishment of a new category of optimum plus sequences allowing for the monitoring of brain atrophy and identifying lesions with a central vein sign, which has gained high interest as a marker on 3T MRI of demyelinating plaques in MS. As described in recent research, the central vein sign shows high accuracy in differentiating between MS and non-MS lesions.

“Many people have a few white spots on neuroimaging, but with MRI so much more available around the world, many of them are being misdiagnosed with MS,” Dr. Traboulsee said. “But the central vein sign, using a very simple MRI technique, can identify lesions with a vein in the center that (distinguishes them as) MS lesions.”

Though the process is still several years from routine clinical use, the proposed update would better implement susceptibility weighted imaging, which has traditionally been used for functional MRI.
 

PML Surveillance

The updates also include recommendations to help in the detection of the rare but potentially serious complication of some disease-modifying therapies of progressive multifocal leukoencephalopathy (PML). “We need a very quick and comprehensive way to monitor patients for PML before symptoms develop,” Dr. Traboulsee said. “The sequences we recommended were based on expert opinion of people who have worked quite a bit with PML in MS, and if one wants to survey for PML it’s only about a 10-minute scan.”

International protocol

Corey Ford, MD, a professor of neurology and director of the MS Specialty Clinic at the University of New Mexico Health Sciences Center in Albuquerque, commented that, with imaging playing such an important role in MS, the lack of adherence to the protocol can be a significant hindrance. “MRI is the most important imaging tool we have in the diagnosing and management of MS, but ... it’s quite amazing how different the sequences that are used can be when imaging centers are asked to image someone with a diagnosis of MS, so it’s a problem,” he said.

Dr. Ford speculated that part of the problem is simply inertia at some imaging centers. “Practices will have been programmed into their protocol for a long time, so when a patient comes in for imaging regarding MS, they may [turn to] their typical sequence,” he said. “There is an inertial barrier to upgrading that sequence, which can involve testing it out on the machine, training the techs to do it that way, and interpreting it for the physician clients who requested the imaging.”

In addition, there is a lack of exposure of MS imaging guidelines in the radiology literature, Dr. Ford added. “Maybe it’s a matter of giving more presentations at meetings that include radiologists, or getting the information out through the manufacturers. I think at the end of the day it could be a combination of all of those things,” he said.

However, the CMSC collaboration could make a big difference, Dr. Ford noted. “This is where the international protocol could be important in terms of making all of this happen,” he said. “What we’re seeing is the confluence of representatives of the U.S. and European centers hash out a consensus, and if it’s international, I think that adds a lot of weight to an eventual implementation on a wider basis.”

“I think the group has done a stellar job, and we should not try to be too focused on adding everyone’s little tweak,” he noted. “If we can get a good baseline foundational imaging sequence that can be implemented worldwide, we would be much better off.”

The CMSC updated imaging guidelines are expected to be published in coming months. The most recent previous updates are available online.

Dr. Traboulsee disclosed relationships with Biogen, Chugai, Roche, Sanofi, and Teva. Dr. Ford and Dr. Li have disclosed no relevant financial relationships.

A version of this article originally appeared on Medscape.com.

Proposed updates to guidelines for magnetic resonance imaging in patients with multiple sclerosis (MS) are in the works to make the Consortium of Multiple Sclerosis Centers protocol and other international guidelines more similar, with the hope that internationally accepted consensus guidelines will improve lagging conformity with the recommendations.

“We’ve always envisioned the guidelines as being international, but now we have harmony with the groups, so this is truly a global protocol,” Anthony Traboulsee, MD, a professor of neurology and director of the MS clinic and neuromyelitis optica clinic at the University of British Columbia in Vancouver, said in presenting the proposed updates during the virtual meeting of the CMSC.

The updates reflect the input of an international expert panel convened by the CMSC in October 2019, made up of neurologists, radiologists, magnetic resonance technologists, and imaging scientists with expertise in MS. Attendees represented groups including the European-based Magnetic Resonance Imaging in MS (MAGNIMS), North American Imaging in Multiple Sclerosis Cooperative, National MS Society, Multiple Sclerosis Association of America, MRI manufacturers, and commercial image analysis.
 

Standardizing scans

While the mission was to review and update the current guidelines, an important overriding objective was to boost universal acceptance and improve the utilization of the protocol, which research shows is surprisingly low. According to one poster presented at the meeting, a real-world MRI dataset of 1,233 sessions showed only 8% satisfied criteria for the T1 sequence outlined in the 2018 guidelines, and only 7% satisfied criteria for the T2 sequence. “In a real-world MRI dataset of patients with MS, the conformance to the CMSC brain MRI guidelines was extremely low,” concluded the authors, who were with Icometrix, in Chicago and Belgium.

David Li, MD, also of the University of British Columbia and cochair of the MRI guideline committee, said the nonconformity has important implications. “Nonstandardized scans, with inconsistent slice thickness and gaps, nonstandardized slice acquisition (not in the subcallosal plane), and incomplete brain coverage, all contribute to scans that are difficult to compare,” he said. Those factors, “allow for assessment of new lesions and lesion activity that are invaluable for diagnosis as well as determining the effectiveness of therapy or the need for initiating/changing therapy.”

Dr. Traboulsee said the lack of adherence to guidelines may simply have to do with a mistaken perception of complexity. “Part of the challenge is MRI centers don’t realize how easy it is to implement these guidelines,” he said in presenting the proposed updates.

Dr. Traboulsee noted that the CMSC has been working with manufacturers to try to incorporate the protocol into the scanners “so that it’s just a button to press” for the MRI. “I think that will get us over a major hurdle of adaptation,” Dr. Traboulsee said. “Most radiologists said once they started using it they were really happy with it. They found they were using it beyond MS for other basic neurologic imaging, so just raising awareness and making things more of a one-step process for individuals to use will be helpful,” he said.
 

Repositioning consistency is key

Among key suggestions that the expert panel proposed for guideline updates include the use of the subcallosal plane for consistent repositioning, which should allow for more accuracy and consistency in the identification of lesions in MS, Dr. Traboulsee said. “A major change reflecting improvements in MRI technology is the ability to acquire high-resolution 3-D images and that’s particularly helpful with fluid attenuation inversion recovery (FLAIR) sequences, which is what we do to identify lesions,” he explained. “The repositioning along the subcallosal line is important because it allows us to easily compare studies over time. It takes very little time but allows us to prepare studies over time much more easily,” he said.

Central vein sign

Another update is the establishment of a new category of optimum plus sequences allowing for the monitoring of brain atrophy and identifying lesions with a central vein sign, which has gained high interest as a marker on 3T MRI of demyelinating plaques in MS. As described in recent research, the central vein sign shows high accuracy in differentiating between MS and non-MS lesions.

“Many people have a few white spots on neuroimaging, but with MRI so much more available around the world, many of them are being misdiagnosed with MS,” Dr. Traboulsee said. “But the central vein sign, using a very simple MRI technique, can identify lesions with a vein in the center that (distinguishes them as) MS lesions.”

Though the process is still several years from routine clinical use, the proposed update would better implement susceptibility weighted imaging, which has traditionally been used for functional MRI.
 

PML Surveillance

The updates also include recommendations to help in the detection of the rare but potentially serious complication of some disease-modifying therapies of progressive multifocal leukoencephalopathy (PML). “We need a very quick and comprehensive way to monitor patients for PML before symptoms develop,” Dr. Traboulsee said. “The sequences we recommended were based on expert opinion of people who have worked quite a bit with PML in MS, and if one wants to survey for PML it’s only about a 10-minute scan.”

International protocol

Corey Ford, MD, a professor of neurology and director of the MS Specialty Clinic at the University of New Mexico Health Sciences Center in Albuquerque, commented that, with imaging playing such an important role in MS, the lack of adherence to the protocol can be a significant hindrance. “MRI is the most important imaging tool we have in the diagnosing and management of MS, but ... it’s quite amazing how different the sequences that are used can be when imaging centers are asked to image someone with a diagnosis of MS, so it’s a problem,” he said.

Dr. Ford speculated that part of the problem is simply inertia at some imaging centers. “Practices will have been programmed into their protocol for a long time, so when a patient comes in for imaging regarding MS, they may [turn to] their typical sequence,” he said. “There is an inertial barrier to upgrading that sequence, which can involve testing it out on the machine, training the techs to do it that way, and interpreting it for the physician clients who requested the imaging.”

In addition, there is a lack of exposure of MS imaging guidelines in the radiology literature, Dr. Ford added. “Maybe it’s a matter of giving more presentations at meetings that include radiologists, or getting the information out through the manufacturers. I think at the end of the day it could be a combination of all of those things,” he said.

However, the CMSC collaboration could make a big difference, Dr. Ford noted. “This is where the international protocol could be important in terms of making all of this happen,” he said. “What we’re seeing is the confluence of representatives of the U.S. and European centers hash out a consensus, and if it’s international, I think that adds a lot of weight to an eventual implementation on a wider basis.”

“I think the group has done a stellar job, and we should not try to be too focused on adding everyone’s little tweak,” he noted. “If we can get a good baseline foundational imaging sequence that can be implemented worldwide, we would be much better off.”

The CMSC updated imaging guidelines are expected to be published in coming months. The most recent previous updates are available online.

Dr. Traboulsee disclosed relationships with Biogen, Chugai, Roche, Sanofi, and Teva. Dr. Ford and Dr. Li have disclosed no relevant financial relationships.

A version of this article originally appeared on Medscape.com.