Consensus recommendations on the management of multiple sclerosis patients in Argentina

doi:10.1016/j.jns.2019.116609

Journal of the Neurological Sciences

Volume 409, 15 February 2020, 116609

https://doi.org/10.1016/j.jns.2019.116609 Get rights and content

Highlights

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The objective of these consensus was to review how MS should be managed in Argentina
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Recommendations focused on diagnosis, tailored treatment, treatment failure and pharmacovigilance
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An early and individualized specific treatment for MS should be used on every patient.
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Neurologists who follow MS patients are responsible for the prescription of the specific treatment
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Patients with suspected MS should be evaluated in an MS care unit and/or by trained MS neurologist

Abstract

Introduction

During the last 20 years, multiple sclerosis (MS) disease has seen major changes with new diagnostic criteria, a better identification of disease phenotypes, individualization of disease prognosis and the appearance of new therapeutic options in relapsing remitting as well as progressive MS. As a result, the management of MS patients has become more complex and challenging. The objective of these consensus recommendations was to review how the disease should be managed in Argentina to improve long-term outcomes in MS patients.

Methods

Results

Recommendations focused on diagnosis, disease prognosis, tailored treatment, treatment failure identification and pharmacovigilance process.

Conclusions

The recommendations of these consensus guidelines attempt to optimize the health care and management of patients with MS in Argentina.

Introduction

More than 2.5 million people worldwide are estimated to be affected by multiple sclerosis (MS), with nearly 15,000 of them living in Argentina [1,2].

During the last 20 years, the disease has seen major changes with new diagnostic criteria, a better identification of disease phenotypes, a better individualization of disease prognosis and the appearance of new therapeutic options in relapsing-remitting as well as progressive MS [3,4]. Thus, the management of MS patients becomes more complex and challenging [5].

Given such complexity, we consider it necessary to make a consensus recommendation about how the disease should be managed in Argentina to improve long-term outcomes in affected MS patients.

Section snippets

Methods

A panel of 36 experts in neurology from Argentina, dedicated to the diagnosis and care of MS patients, gathered both virtually and in person during 2018 and 2019 to carry out a consensus recommendation on the management of MS patients in Argentina. The management of MS included the following topics: a) diagnosis of MS; b) disease prognosis and personalized treatment; c) treatment failure identification; and d) pharmacovigilance process. To achieve consensus, the methodology of “formal

Discussion

There is great research and innovation developing in the field. Consequently, the management of MS patients is becoming more complex and challenging due to the need for early and accurate diagnosis of MS, the recommendation to initiate early and tailored treatments, the consideration of switching treatments when failure is identified, the need to search for and treat co-morbidities and consider symptomatic treatments, and the need to correctly manage all potential adverse events related with

Funding

Research was supported by a grant from Biogen Argentina, Merck Argentina, Novartis Argentina and Roche Argentina from Argentina.

Declaration of competing interest

RA, AAP, EAB, MEB, MB, EC, MCC, ND, MIG, OG, DG, MJH, JPH, MJ, EK, RL, JM, PGN, RP, MLS, VS, DS, AT, SAV, AV, CV has nothing to disclose. EC has received reimbursement for developing educational presentations, educational and research grants, consultation fees and travel stipends from Biogen, Genzyme, Merck, Novartis. AGB has received reimbursement for developing educational presentations, educational and research grants, consultation fees and travel stipends from Biogen, Genzyme, Novartis,

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Clinical characterization of long-term multiple sclerosis (COLuMbus) patients in Argentina: A cross-sectional non-interventional study
2024, Multiple Sclerosis and Related Disorders
Most Multiple Sclerosis (MS) clinical trials fail to assess the long-term effects of disease-modifying therapies (DMT) or disability.
COLuMbus was a single-visit, cross-sectional study in Argentina in adult patients with ≥10 years of MS since first diagnosis. The primary endpoint was to determine patient disability using the Expanded Disability Status Scale (EDSS). The secondary endpoints were to evaluate the distribution of diagnoses between relapsing-remitting MS (RRMS) and secondary progressive MS (SPMS), patient demographics, disease history, and the risk of disability progression. The relationship between baseline characteristics and the current disability state and the risk of disability progression was assessed.
Out of the 210 patients included, 76.7 % had a diagnosis of RRMS and 23.3 % had been diagnosed with SPMS, with a mean disease duration of 17.9 years and 20.5 years, respectively. The mean delay in the initial MS diagnosis was 2.6 years for the RRMS subgroup and 2.8 years for the SPMS subgroups. At the time of cut-off (28May2020), 90.1 % (RRMS) and 75.5 % (SPMS) of patients were receiving a DMT, with a mean of 1.5 and 2.0 prior DMTs, respectively. The median EDSS scores were 2.5 (RRMS) and 6.5 (SPMS). In the RRMS and SPMS subgroups, 23 % and 95.9 % of patients were at high risk of disability, respectively; the time since first diagnosis showed a significant correlation with the degree of disability.
This is the first local real-world study in patients with long-term MS that highlights the importance of recognizing early disease progression to treat the disease on time and delay disability.
Management strategies of high-efficacy therapies for multiple sclerosis in clinical practice
2023, Neurologia Argentina
En la actualidad existe un importante número de opciones en terapias modificadoras de la enfermedad en esclerosis múltiple (EM), las cuales pueden ser categorizadas como de baja, moderada y alta eficacia según su capacidad para controlar la actividad de la enfermedad. Al existir pocos estudios comparativos entre terapias de alta eficacia (TAE), existe incertidumbre sobre cuál es el mejor momento para indicarlas o reemplazarlas.
Asistir a los médicos tratantes en la toma de decisiones sobre la elección y uso de terapias de alta eficacia, en diferentes escenarios frente a la persistencia de actividad, progresión de la discapacidad, presencia de factores de mal pronóstico o efectos adversos bajo tratamiento.
Un grupo de neurólogos argentinos con experiencia en el manejo de pacientes con EM fue convocado para debatir e identificar opciones válidas para la estrategia de indicaciones y manejo de las TAE (cladribine, ocrelizumab, ofatumumab, natalizumab y alemtuzumab).
Este trabajo pretende servir de orientación para los médicos tratantes en caso de presentar dudas de manejo de TAE, de acuerdo con lo que harían en su consultorio referentes en manejo de la EM en Argentina.
There are currently a significant number of options for disease-modifying therapies in multiple sclerosis (MS), which can be categorized as low, moderate, or highly effective based on their ability to control disease activity. As there are few comparative studies between high-efficacy therapies (HET), there is uncertainty about the best time to indicate or replace them.
To assist treating physicians in making decisions about the choice and use of highly effective therapies, in different scenarios regarding persistence of activity, progression of disability, presence of poor prognostic factors, or adverse effects under treatment.
A group of Argentine neurologists with experience in the management of patients with MS was convened to discuss and identify valid options for the strategy of indications and management of HETs (cladribine, ocrelizumab, ofatumumab, natalizumab, and alemtuzumab).
This work aims to serve as a guide for treating physicians in case of doubts about the management of SAD, according to what they would do in their office referring to the management of MS in Argentina.
Neuro rehabilitation effectiveness based on virtual reality and tele rehabilitation in people with multiple sclerosis in Argentina: Reavitelem study
2023, Multiple Sclerosis and Related Disorders
Virtual Reality (VR) has emerged as a new treatment approach in neurorehabilitation (NR). REAVITELEM Study is a specific NR intervention program based on VR at center (VRC) and tele-rehabilitation (TR) in Argentina.
Methods First national multicenter study with a 12-week program intervention of VRC and TR. Participants were assessed at baseline, at 6th and 12th week. Phase I: recruitment and gather of 5 NR Centers from Argentina by the coordinator center (INEBA) to unify evaluation and intervention criteria. Phase II, all centers completed VRC an TR programs. Intervention was 30-minute session, twice a week for 12 weeks. Outcome measures: Expanded Disability Status Scale (EDSS), Fist and Key Pinch Dynamometry, Beck Depression Inventory-Fast Screen, Fatigue Severity Scale, Functional Independence Measure (FIM), International Questionnaire investigating Quality of life in MS (MusiQol) and a Visual Analogue Scale (VAS) of satisfaction after treatment.
Results A total of 54 PWMS (23 males) were recruited for VRC. Afterwards, 14 completed TR. The mean age for VRC was 44.72 (SD ± 13.74) and 41.71 (SD ± 10.5) for TR. The median EDSS was 4, 75 for VR. At VRC, 42 have RRMS, 8 have SPMS and 4 PPMS. At TR, 13 have RRMS and 1 have SPMS. The VAS reported an excellent level of satisfaction after treatment with an average of 9, 02 (SD±1.35) in VRC and 9.42 (SD±0.66) in TR. There were significant differences for MusiQol, which improved from baseline to the post-intervention assessment at VRC (p=<0.001) and at TR (p = 0.004) as well as FIM post-intervention assessment at VCR (p = 0.02) and TR (p = 0.04).
Conclusion this study suggest that the NR treatment based on VR in MS in Argentina, is an additional effective tool, which favors improvements in the level of functioning in activities of daily living, quality of life, mood, and satisfaction with the treatment.
Health disparities in the real world of patients with multiple sclerosis
2023, Neurologia Argentina
En muchos países, desarrollados o no, existen disparidades sociales, económicas, culturales, étnicas, ambientales, políticas y también de salud.
En el presente trabajo se pone de relieve la existencia de disparidades de salud (DS) en la atención de pacientes afectados de esclerosis múltiple (EM), en particular aquellas observadas en el mundo real de la asistencia de la enfermedad.
Entre las más frecuentes se mencionan el acceso limitado a medicación específica, a resonancias magnéticas (RM) y otros estudios diagnósticos imprescindibles, y a neurorrehabilitación (NRH), así como el descuido de las distintas discapacidades, calidad de vida (CV) y dificultades de la vida diaria que ocasionan la afección, además de otras como disparidad de edad, género, etnicidad, estatus socioeconómico, medio ambiente, vivienda y trabajo. En la literatura actual se mencionan con creciente frecuencia datos del mundo real, no provenientes de estudios clínicos aleatorizados (ECA), sobre cuya base se toman decisiones diagnósticas y terapéuticas en la práctica diaria. Estos datos, debidamente analizados, pueden traducirse en evidencias duras, siempre y cuando contemplen DS, en la actualidad escasamente consideradas al evaluar la atención y evolución de los pacientes con esta enfermedad.
Las DS son evidencias relevantes en el mundo real de los pacientes con EM y deben incluirse al evaluar y tomar decisiones sobre su atención. Corregirlas contribuye a una mejor equidad en salud.
Many countries, developed or not, endure social, economic, cultural, ethnic, environmental and also health disparities.
To point out health disparities occurring in the real world care of patients with multiple sclerosis.
Recently published data increasingly mention health disparities in multiple sclerosis obtained from real world data and not from randomized clinical trials. The most prevalent include limited access to specific medication, magnetic resonance imaging, other essential diagnostic studies, neurorehabilitation. Disregard of the various handicaps caused by the disease (poor quality of life, difficulties of daily living), age, gender, ethnicity, socioeconomic status, environment, dwelling and employment are also mentioned. Analyzed with adequate instruments, these data might have hard evidence value on health disparities, at present underestimated when assessing the care of patients with this disease, and consequently allowing for more scientifically rigorous diagnostic and therapeutic decisions.
Health disparities are relevant evidence in multiple sclerosis patients and should be included in the assessment and decision making of their management. Correcting them would contribute to a better equity in health care.
Highly active multiple sclerosis and its influence in the choice of treatment
2021, Neurologia Argentina
No existe una definición universalmente aceptada de esclerosis múltiple altamente activa (EMAA), y no existen guías de práctica clínica ni consensos que la definan con claridad, por lo que la ausencia de esta definición dificulta la toma de decisiones terapéuticas.
Definir con la mejor precisión posible la EMAA, y armar una propuesta de diagnóstico y manejo de estos pacientes.
Un grupo de neurólogos argentinos con experiencia en el manejo de pacientes con esclerosis múltiple fue convocado para debatir e intentar dar respuesta a las preguntas más frecuentes sobre EMAA.
La presencia de recaídas, en primer lugar, de nuevas lesiones con realce, en segundo, y la aparición de nuevas lesiones T2 en el transcurso de un año, en tercero, son suficientes para definir la EMAA. No se logró identificar con precisión el número de nuevas lesiones en T2 o con captación de contraste que se requieren para cumplir la definición. La mejor opción recomendada de tratamiento para estos pacientes, ya sean naive o bajo otro tratamiento, son las terapias de alta eficacia.
There is no universally accepted definition of highly active multiple sclerosis (HAMS), and there are no clinical practice guidelines or consensus that clearly defines it, so the absence of this definition makes it difficult to make therapeutic decisions.
To define HAMS with the best possible precision, and to put together a proposal for the diagnosis and management of these patients.
A group of Argentine neurologists with experience in the management of patients with multiple sclerosis was convened to discuss and try to answer the most frequent questions about HAMS.
The presence of relapses in the first place, of new lesions with enhancement in the second, and the appearance of new T2 lesions in the course of one year are enough to define HAMS. It was not possible to accurately identify the number of new T2 or contrast-enhanced lesions that are required to meet the definition. The best recommended treatment option for these patients, whether they are naive or under other treatment, are highly effective therapies.
Clinical practice patterns in multiple sclerosis management: Mexican consensus recommendations
2021, Multiple Sclerosis and Related Disorders
Citation Excerpt :
Cristiano and Rojas, 2017) Thus, an Argentinian MS panel expert established recommendations to improve long-term outcomes taking into account aspects, such as early and accurate diagnosis, individual tailored treatment, and a neurologist-supervised pharmacovigilance process. ( Cristiano et al., 2020) Actually, this same expert group have already proposed recommendations for the identification of treatment failure in relapsing-remitting multiple sclerosis (RRMS). ( Cristiano et al., 2018) Furthermore, other recommendations on primary progressive multiple sclerosis, (Cristiano et al., 2018) radiologically isolated syndrome (RIS), (Carnero Contentti et al., 2019) and pregnancy have been also published. (
Multiple sclerosis affects more than 2 million people. Clinical decisions are performed under evidence-based medicine. The appearance of new disease-modifying therapies and changes in diagnostic criteria complicates the decision-making process in clinical practice.
To characterize the criteria for radiologically isolated syndrome (RIS), clinically isolated syndrome (CIS), and relapsing-remitting multiple sclerosis (RRMS) by Mexican neurologists in a real-world setting.
A two-round modified Delphi method (RAND/UCLA) was applied.
In RIS, LP, spinal cord MRI and VEP should be included in diagnostic testing; DMT initiation is not necessary. A follow-up MRI within 3 months are recommended. In CIS, corticosteroid therapy should be initiated at first relapse; both simple and Gd-enhanced MRI is mandatory. LP, selective blood tests, and NMO-IgG/AQP4 antibodies should be performed as complementary. IFN beta or GA were the most suitable DMTs for treating high-risk CIS. Patients with RRMS should begin with DMT at diagnosis, include a follow-up MRI if a patient had 2 relapses within 6 months. GA and oral DMTs are the most eligible DMTs for mild RRMS. Monoclonal antibodies-based therapy is chosen when disability is present. Radiological criteria for switching DMT included >1 Gd+ lesion and >2 new T2 lesions.
Although many coincidences, there are still many hollows in the medical attention of MS in Mexico. This consensus recommendation could be helpful to implement better evidence-based recommendations and guidelines in a real-world setting.

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Consensus recommendations on the management of multiple sclerosis patients in Argentina

Highlights

Abstract

Introduction

Methods

Results

Conclusions

Introduction

Section snippets

Methods

Discussion

Funding

Declaration of competing interest

Mult. Scler Relat. Disord.

Mult. Scler Relat. Disord.

Lancet

Transplant. Proc.

Lancet Neurol.

Lancet Neurol.

J. Neurol. Sci.

J. Neurol. Sci.

J. Neurol. Sci.

Lancet Neurol.

Mult. Scler Relat. Disord.

J. Neurol. Sci.

Brain Res.

Autoimmun. Rev.

J. Neuroimmunol.

J. Neurol. Sci.

J. Neurol. Sci.

Lancet

Lancet

Lancet

Lancet Neurol.

Mult. Scler Relat. Disord.

Neuroimaging Clin. N. Am.

J. Neurol. Sci.

J. Neurol. Sci.

J. Neurol. Sci.

Defining the clinical course of multiple sclerosis: the 2013 revisions

Neurology

The multiple sclerosis care unit

Mult. Scler.

Tools for measuring patient safety in primary care settings using the RAND/UCLA appropriateness method

BMC Fam. Pract.

Diagnosis of multiple sclerosis: revisions of the McDonald criteria 2017 – continuity and change

Curr. Opin. Neurol.

Central nervous system infectious diseases mimicking multiple sclerosis: recognizing distinguishable features using MRI

Arq. Neuropsiquiatr.

Differential diagnosis of suspected multiple sclerosis: a consensus approach

Mult. Scler.

Evidence-based guidelines: MAGNIMS consensus guidelines on the use of MRI in multiple sclerosis-clinical implementation in the diagnostic process

Nat. Rev. Neurol.

Evidence-based guidelines: MAGNIMS consensus guidelines on the use of MRI in multiple sclerosis--establishing disease prognosis and monitoring patients

Nat. Rev. Neurol.

Diagnosis, differential diagnosis, and misdiagnosis of multiple sclerosis

Continuum (Minneap. Minn.)

Relapse severity and recovery in early pediatric multiple sclerosis

Mult. Scler.

Multiple sclerosis relapses: a multivariable analysis of residual disability determinants

Acta Neurol. Scand.

Demyelinating events in early multiple sclerosis have inherent severity and recovery

Neurology

The natural history of multiple sclerosis: a geographically based study. I. Clinical course and disability

Brain

Early clinical predictors and progression of irreversible disability in multiple sclerosis: an amnesic process

Brain

The natural history of multiple sclerosis: a geographically based study 9: observations on the progressive phase of the disease

Brain

Poor early relapse recovery affects onset of progressive disease course in multiple sclerosis

Neurology

Clinical and demographic predictors of long-term disability in patients with relapsing-remitting multiple sclerosis: a systematic review

Arch. Neurol.

Course and prognosis in early-onset MS: comparison with adult-onset forms

Neurology

Early prognostic factors for disability in multiple sclerosis, a European multicenter study

Acta Neurol. Scand.

The natural history of multiple sclerosis: a geographically based study 10: relapses and long-term disability

Brain

Contribution of different relapse phenotypes to disability in multiple sclerosis