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Apr 30 / Springer Healthcare

AAN 2021 In-depth Report: Multiple Sclerosis

Description

This AAN 2021 in-depth report provides an insight into challenges in the differential diagnosis and management of multiple sclerosis.

American Academy of Neurology

AAN Virtual 73rd Annual Meeting

April 17th – 23rd, 2021

In-Depth Report: Multiple Sclerosis

For the first time in its history, the 73rd Annual Meeting of the American Academy of Neurology (AAN) – the world’s premier neurology meeting – was held in a fully virtual format from April 17th to 22nd 2021

Welcome to AAN 2021


AAN President James Stevens

James Stevens, AAN President

The 2021 virtual AAN annual meeting was centred around a rich educational and scientific programme including over 90 expert-led educational courses, more than 2000 scientific abstracts and seven key plenary sessions featuring leaders in neurology.

AAN President James Stevens, Fort Wayne, USA, began this key plenary session with presentation of the President’s Award followed by the Presidential Lecture entitled: ‘Disruption: How to Pivot from Uncertainty to Success - the AAN Story.’ Dr Stevens proposed a focused five-pronged approach to navigating crises such as COVID-19.

 
Crises such as COVID-19 can be averted by improving focus, formulation, execution, communication and persistence

 

Five-pronged approach to navigating crises such as COVID-19.

“What a year it has been - unprecedented does not even begin to describe what we have all been through. We’ve faced uncertainty, exhaustion and challenge but we are emerging stronger, resilient and prepared to face our new future. ”

President James Stevens, Fort Wayne, USA


AAN President-Elect Orly Avitzur

Orly Avitzur, AAN President-Elect

The 2021 virtual AAN annual meeting was centred around a rich educational and scientific programme including over 90 expert-led educational courses, more than 2000 scientific abstracts and seven key plenary sessions featuring leaders in neurology.

There then followed a brief welcome address by AAN President-Elect Orly Avitzur, Tarrytown, USA, who will be charged with leading the academy over the next two years. As we enter the recovery phase of the pandemic, Dr Avitzur outlined some exciting AAN programmes for the future including an increasing focus on hybrid educational and scientific meetings, studies to support telemedicine and an expanded emphasis on well-being.

 
 

MULTIPLE SCLEROSIS

Challenges in differential diagnosis and treatment of multiple sclerosis

Lilyana Amezcua

An educational course adopted a case-based approach to explore the increasingly complex challenges which clinicians face around the differential diagnosis and treatment of multiple sclerosis (MS) and related disorders.

Focusing on diagnosis, Lilyana Amezcua, Los Angeles, USA, explained that MS is a complex disease with multiple endophenotypes and McDonald diagnostic criteria continue to evolve. Many patients previously labelled as clinically isolated syndrome (CIS) now receive the diagnosis of MS, making the prognosis of both CIS and relapsing-remitting MS (RRMS) more benign. As a result, patients diagnosed more recently tend to reach disability milestones at an older age. Dr Amezcua emphasised that early diagnosis and treatment of MS remains critical and, once diagnosed, it is important to assess patients for the presence of poor prognostic indicators, initiate disease-modifying therapy (DMT) and manage symptoms and comorbidities.

 
“High-risk radiologically isolated syndrome (RIS) and prodrome may become part of the MS spectrum in the next version of the McDonald criteria.”

Lilyana Amezcua, Los Angeles, USA

Le Hau, Las Vegas, USA, gave an overview of differential diagnosis and treatment considerations in MS, cautioning that the need for timely DMT initiation to delay disability progression must be balanced against the importance of accurate diagnosis. In particular, it is vital to avoid inappropriate DMT exposure in those patients with red flags that point to alternative non-MS diagnoses. In total, 36 major red flags have been identified based on analysis of the clinical data, together with an estimated 79 clinical and paraclinical red flag findings. On treatment selection, Dr Hau noted the importance of incorporating patient factors and beliefs and carrying out continual monitoring for the need to change DMT. Potential reasons for switching may include lack of efficacy, poor tolerability/compliance or patient factors that alter the underlying safety risk.

 
The use of DMTs to manage MS

Jacqueline Bernard, Portland, USA, reviewed the mechanisms of action and risk-benefit ratios of the rapidly expanding armory of DMTs available to manage MS. Important recent additions include the new sphingosine-1-phosphate (S1P) receptor modulators ponesimod and ozanimod, and the dimethyl fumarate bioequivalent monomethyl fumarate. When confronted with a new diagnosis of RRMS, Dr Bernard highlighted family planning, disease severity and comorbidities as key clinical decision points. General safety concerns for all DMTs include progressive multifocal leukoencephalopathy risk, vaccination responses and pregnancy.

For female RRMS patients who are planning pregnancy, glatiramer or interferons should be considered. Dr Bernard specifically recommended an induction therapy strategy for male RRMS patients with spinal cord disease due to the high risk of disability. Ocrelizumab currently remains the only FDA-approved treatment for primary progressive MS but potential benefits must be weighed against immunosenescence and infectious risks. All DMTs for relapsing MS have now received retrospective indications for active secondary progressive MS due to an FDA label shift in 2019. When to stop DMTs continues to be a crucial clinical question which is being explored further in the DISCO MS-PICORI study (NCT03073603) of patients aged ≥55 years which is due to complete in February 2022.

“Switching DMTs is recommended if there is one or more relapse(s), two or more new MRI-detected lesions or decreased disability on examination over a 1-year period of using a DMT.”

Jacqueline Bernard, Portland, USA

National MS Society COVID-19 vaccination recommendations, including timings considerations for DMTs

National MS Society COVID-19 vaccination recommendations

 
Symptom management in MS

Effective management of common symptoms associated with MS remains a critical determinant of patients’ quality of life, function and safety. Carrie Hersch, Cleveland, USA, explained that DMTs generally have little or no effect on MS symptoms, which can be varied, unpredictable and often ‘invisible’. Treatment of MS symptoms therefore centres on medication, which should be deployed in conjunction with physical therapy, occupational therapy, psychotherapy and lifestyle strategies. Only modest success has been achieved with symptomatic treatments for cognitive dysfunction so cognitive rehabilitation and physical activity remain key interventions. The burden of fatigue in MS is immense and Dr Hersch stressed the importance of addressing both primary and secondary causative factors; the latter including depression, drug side effects, sleep disorders and physical deconditioning.

Medical management options include amantadine and modafinil. For emotional disorders, psychotherapy (such as cognitive behavioural therapy and mindfulness) should be married with psychopharmacology (of which antidepressants are the cornerstone) because the combination is more effective than either treatment strategy alone. To combat heat sensitivity, lifestyle and self-care measures such as cooling products, consumption of cold fluids and cool bathing are recommended. As a general principle when treating MS symptoms, Dr Hersch explained that trial and error, rather than a targeted approach, may be required to find the appropriate medication or strategy to address a particular patient’s symptom(s).

Symptom management in MS

Most common MS symptoms

“Addressing symptoms that impact MS health is a key component to optimal long-term management.”

Carrie Hersch, Cleveland, USA

In the presentation that followed, Jacqueline Nicholas, Columbus, USA, homed in specifically on the management of symptoms of bladder/bowel dysfunction, sexual dysfunction and spasticity which occur commonly in MS and can impact significantly on patients’ quality of life. Bladder/bowel symptoms may be improved by a tandem approach of lifestyle/behavioural modification and medication. In complex cases, Dr Nicholas advised referral to urology for advanced testing. Intra-detrusor botulinum A toxin injections have also demonstrated significant improvements in patients with overactive bladder that fail to respond to anticholinergic medication. On spasticity and sexual dysfunction, Dr Nicholas stressed the importance of regularly assessing patients for these symptoms and addressing them early.

 
Closing Remarks

Dr. Anthony Fauci

Hailing this year’s annual meeting as ‘ANN excellence delivered unconventionally’ outgoing President Dr Stevens closed the congress by handing the reins of leadership to the new ANN President Dr Avitzur with the passing of the gavel. Dr Avitzur expressed her hope for an optimistic future with next year’s AAN meeting, due to take place in Seattle, Washington, between the 2nd and 8th April 2022, providing the opportunity for members to come back together again in person.

 
 

©Springer Healthcare 2021. This content has been independently selected and developed by Springer Healthcare and licensed by Roche for Medically. The topics covered are based on therapeutic areas specified by Roche. This content is not intended for use by healthcare professionals in the UK, US or Australia. Inclusion or exclusion of any product does not imply its use is either advocated or rejected. Use of trade names is for product identification only and does not imply endorsement. Opinions expressed do not reflect the views of Springer Healthcare. Springer Healthcare assumes no responsibility for any injury or damage to persons or property arising out of, or related to, any use of the material or to any errors or omissions. Please consult the latest prescribing information from the manufacturer for any products mentioned in this material.