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A total of 80 consensus recommendations have been developed to guide best-practice management of multiple sclerosis in Australia and New Zealand.
Multiple sclerosis (MS) is a chronic inflammatory demyelinating and degenerative disease of the central nervous system. It is the leading cause of non-traumatic chronic neurological disability in young adults in high income countries, and is most commonly diagnosed in people between the ages of 20 and 50 years. MS is three times more common among women than men, and there is currently no cure.
While international guidelines for the management of MS exist, the MS Group of the Australian and New Zealand Association of Neurologists (ANZAN) identified the need for up-to-date guidelines for Australia and New Zealand that encompass locally available therapies, government subsidies and local practice. After engagement with a panel of 34 MS neurologists and review by MS specialists, clinicians and support groups, 80 consensus recommendations were developed. These recommendations have now been outlined in a two-part consensus statement published in the Medical Journal of Australia.
“The aim of this position statement is to provide a practical resource for clinicians (general practitioners, general physicians and general neurologists) on current best-practice consensus recommendations for managing adults with MS in the Australian and New Zealand health care settings,” the authors wrote.
Disease modifying therapies (DMTs)
Part 1 of the consensus statement discusses recommendations relating to disease modifying therapies currently available on the Australian Pharmaceutical Benefits Scheme and the New Zealand Pharmac.
“Although the treatments for MS are not curative, there have been significant improvements in ameliorating disease activity and disability progression with the development and availability of effective DMTs,” the authors wrote.
“DMTs for MS should be initiated and supervised by a neurologist and selection individualised to the person with MS. The choice of DMT is determined by considerations including disease phenotype, disease activity, drug efficacy, drug risk profile, John Cunningham Virus (JCV) antibody status, comorbid conditions, pregnancy considerations, local accessibility, route of administration, and patients’ personal preferences, values and goals.”
The consensus statement outlines the recommended evaluations that should take place before commencing DMTs, including pre-immunotherapy screening, review of the patient’s immunisation history, and performing baseline laboratory tests and examination.
The statement also details recommendations for ongoing monitoring of disease activity while on DMTs and indications for when DMTs may need to be switched or discontinued.
Risk mitigation, special situations and lifestyle measures
Part 2 of the consensus statement discusses recommendations related to risk mitigation during treatment with DMT, managing DMT in special situations, and general lifestyle measures for MS management.
Risk mitigation recommendations include laboratory monitoring, anti-JCV antibody testing, up-to-date immunisation, and cancer screening due to increased risk of malignancy associated with DMT.
Special situations that may need to be considered during treatment with DMTs include active infection, COVID-19 infection, and current or previous malignancy.
Given the higher prevalence of MS in women, significant attention is given to recommendations for management of DMTs during pregnancy and breastfeeding.
“Pregnancy plans should be discussed with women of childbearing potential before commencing DMT and regularly thereafter to carefully plan the best approach to DMT selection and management,” the authors wrote.
“The decision to continue or temporarily discontinue DMTs during pregnancy is individualised based on factors such as the individual’s clinical and radiological disease activity and disease severity, DMT safety in pregnancy, the risk of rebound activity after DMT discontinuation, and personal preferences and values.”
In terms of lifestyle modifications, the authors note that there is currently insufficient evidence to support any specific dietary interventions for MS, but do recommend regular exercise, smoking cessation and vitamin D supplementation.
Part 2 of the statement concludes by highlighting the vital role of general practitioners in the care of people with MS.
“Communication between neurologists and general practitioners is crucial in caring for people with MS. General practitioners can assist with risk mitigation on DMTs, such as immunisations and routine cancer screening, as well as general health measures, such as assisting with smoking cessation, maintenance of a healthy diet and exercise, and monitoring cardiovascular health.”
Read Part 1 of the consensus statement in the Medical Journal of Australia.
Read Part 2 of the consensus statement in the Medical Journal of Australia.
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