Redefining relapses: blurring the boundary between clinical and MRI monitoring

Is it time to rethink our definition of a relapse? #MSBlog #MSResearch


"I gave a talk today at a meeting that is focusing on the commissioning of MS services in England. I was discussing the future of MS treatments and made a case for “Saving Brain” with the aim of preventing or reducing end-organ damage in MSers. To do this we need to go beyond the current definition of NEDA (no evident disease activity) and target the base of the “MS iceberg” and try and normalise brain atrophy rates and spinal fluid neurofilament levels. I know that this target may seem unreasonable when some MSers in the country are have difficulty getting simple walking aids or have difficulty accessing their local or regional neurological services for an assessment for DMTs. Am I pushing the bubble too far? Do we have enough evidence that normalising brain atrophy rates makes a difference?"



"One suggestion I made was that we need to challenge the older NICE guidance on not being able to escalate DMTs on MRI criteria alone. To escalate from platform, or 1st-line, DMTs you need to have clinical attacks. However, the new NICE guidance allows alemtuzumab to be prescribed to MSers with active MS defined either clinically or on MRI. The latest guidelines therefore recognise that clinical attacks and MRI activity mean the same thing; i.e. that MS is active. I therefore propose that we stop referring to new T2-lesions, or gadolinium-enhancing T1-lesions, as MRI activity and call them subclinical, or asymptomatic, relapses. If we accept this definition it will change the way we classify MS and our approach to its management; for example we can change the meaning of current NICE guidance’s when they refer to relapses. We would also have to offer PPMSers who have active MRIs DMTs. What do you think?"

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