MENACTRIMS Update Guidelines for Diagnosis and Treatment of Multiple Sclerosis

The Middle East North Africa Committee for Treatment and Research in Multiple Sclerosis (MENACTRIMS) released an update to their 2019 guidelines on the diagnosis and treatment of multiple sclerosis (MS). A panel of experts who manage MS in the MENA region issued the revised 2023 guideline published in the journal Multiple Sclerosis and Related Disorders.

Diagnosis of Multiple Sclerosis

The diagnosis of MS relies on a comprehensive history, neurological examination to evaluate dissemination in space (DIS) and time (DIT), and signs and symptoms of MS. Tests to support MS diagnosis include magnetic resonance imaging (MRI), evoked potential studies, and cerebrospinal fluid (CSF) analysis. The recommended protocol for MRI in MS is the 2021 MAGNIMS-CMSC-NAIMS consensus guidelines.

Treatments for Different Types of MS

Acute Relapse

Patients with acute MS relapse should be treated with a 3- to 5-day course of intravenous methylprednisolone (IV-MP) with a daily dose ranging from 500 to 1000 mg. Plasmapheresis may be considered in patients with severe disability who fail 1 or 2 courses of IV-MP. 

Radiologically Isolated Syndrome (RIS)

Individuals with RIS should be referred to a specialized MS center for management. Consider treatment for patients with RIS if they have multiple risk factors and evidence of new lesions. 

There is a clear need to unify and update the diagnostic and therapeutic paradigms across the MENA region as most countries in the region are in the process of establishing specialized MS centers.

Clinically Isolated Syndrome (CIS)

Patients with CIS should receive treatment based on predictive factors, including high MRI lesion load, severe relapse, incomplete recovery, CSF oligoclonal bands, and multifocal onset. It is not recommended to treat patients with CIS who have a normal brain MRI. 

Relapsing-Remitting Multiple Sclerosis (RRMS)

There are over 20 disease modifying therapies (DMTs) that are approved for the treatment of RRMS. The current guideline discusses emerging DMTs, such as ofatumumab, ponesimod, and ublituximab, which were not included in previous guidelines.

In patients who are treatment-naïve with moderately active disease, moderate efficacy DMTs (interferons-beta [IFN-beta], glatiramer acetate [GA], teriflunomide, or dimethyl fumarate [DMF]) are recommended in addition to high-efficacy DMTs (sphingosine-1-phosphate receptor [S1PR] modulators, cladribine, B-cell depleting therapies).

For individuals with highly active disease, high-efficacy DMTs or natalizumab should be initiated. The off-label use of rituximab is recommended for all levels of activity in areas where other options are unavailable. 

Progressive MS 

Siponimod or B cell-depleting therapies can be considered in patients with active secondary progressive MS (SPMS) aged 60 or younger with an Expanded Disability Status Scale (EDSS) score of 6.5 or less. Ocrelizumab is an option for patients with primary progressive MS (PPMS) who are age 55 or younger with an EDSS of 6.5 or less and who have a disease activity of 10 to 15 years or less. 

Autologous Hematopoietic Stem Cell Therapy (AHSCT) Consideration

Consider AHSCT for the following:

  • Evolving aggressive MS and suboptimal response to a high-efficacy medication
  • Highly active disease and suboptimal response to at least 2 high efficacy DMTs
  • Progressive MS with active inflammation and not responding to DMTs

Pregnancy and Breastfeeding With MS

Family planning is advised to occur once the disease is in remission for at least 1 year. Patients on IFN-beta, GA, and natalizumab can continue their DMT until conception is confirmed; IFN-beta and GA can be continued throughout pregnancy. The S1PR modulators, alemtuzumab, and cladribine require washout periods. 

Patients on IFN-beta, GA, natalizumab, B-cell depleting therapies, and alemtuzumab may breastfeed. For patients on monoclonal antibodies, initiate breastfeeding at least 1-week post-partum and 4 hours after infusion. Individuals on oral teriflunomide, S1PR modulators, cladribine, and DMF should avoid breastfeeding.

Pediatric MS 

Children with active MS can initiate treatment with DMF, fingolimod, or teriflunomide. If patients continue to have ongoing clinical or radiological disease activity despite the use of these agents, other high-efficacy DMTs may be considered. 

Multiple Sclerosis in MENA Regions

With the increase in MS incidence and prevalence worldwide, including the MENA regions, the establishment of specific guidelines becomes increasingly important.

“There is a clear need to unify and update the diagnostic and therapeutic paradigms across the MENA region as most countries in the region are in the process of establishing specialized MS centers,” guideline authors wrote.

Disclosures:  Several study authors have declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of the authors’ disclosures.

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