multiple sclerosis management

MULTIPLE SCLEROSIS DISEASE MODIFYING THERAPY

Once therapy is initiated, this is the protocol for followup:

At 12 months, or if there is breakthrough disease:If the patient is on interferons:

1. Test neutralizing antibodies [NAB] (high is abnormal) and MX1 Biological activity (low is abnormal)
2. If NAB is <20, followup testing of NAB in 6 months
3. If NAB is >20, switch to a different med if symptomatic. But if asymptomatic repeat in 6 months. If again positive, switch.

If the patient is on Copaxone:

1. Switch to an interferon
2. Using Disease Activity for decision making:

High disease activity:

       Switch medication regardless of antibodies

Intermediate disease activity:

       Use NAB and MX1 to make a decision. If antibodies abnormal, switch medications

Low disease activity:

       Switch only if antibodies consistently positive 6 months apart

Remember, antibodies should be tested only after at least 30 days have passed since the last steroid therapy.

Second tier medications:

Fingolimod

Natalizumab

Third tier:

Mitoxantrone

Last resort:

Rituximab