Advise that patients should discuss with their healthcare professionals if they are planning to start or extend their family or become pregnant, especially in those who take disease-modifying therapies.
Multiple Sclerosis (MS)
NICE guideline [NG220] Multiple sclerosis in adults: management. Published: Jun 2022.
NICE CKS Multiple sclerosis. Last revised: May 2024.
ECTRIMS International Advisory Committee on Clinical Trials in MS. McDonald Diagnostic Criteria
Background Information
Clinical Features
Typical presents in 20-50 y/o and is more common in females
MS-indicative patterns:
- Symptoms tend to evolve over >24 hours
- Symptoms may persist over days and weeks, then improve (relapse-remitting)
- History of previous neurological symptoms
- No signs of infection
Most common initial presentations:
| Presentation | Clinical features |
|---|---|
| Optic neuritis (20-30%) |
Optic neuritis is more commonly unilateral, if bilateral one must exclude neuromyelitis optica which is often confused with MS and needs urgent treatment |
| Transverse myelitis |
|
| Cerebellar features |
|
| Brainstem syndromes |
|
Guidelines
Investigation and Diagnosis
If MS is suspected based on clinical features → refer to consultant neurologist (only a consultant neurologist should make a diagnosis of MS)
1st line investigations for suspected MS
- MRI brain + spinal cord (with and without gadolinium contrast) – most important investigation
- Lumbar puncture for CSF analysis
Diagnostic Test Interpretation
This section is more likely to be examined, instead of having to learn the full McDonald Criteria which is reserved for specialists.
| Investigation | Findings in MS |
|---|---|
| MRI | Multiple sclerotic plaques and Dawson fingers (finger-like radial extensions)
|
| CSF analysis | Unmatched oligoclonal bands
|
Matched oligoclonal bands: Identical bands in CSF and serum indicate systemic immunoglobulin production with no intrathecal synthesis and are not suggestive of multiple sclerosis.
Unmatched (CSF-restricted) oligoclonal bands: Bands present in CSF but absent in serum indicate intrathecal / CNS IgG synthesis, strongly supporting multiple sclerosis.
McDonald Criteria (2024 Revised)
The previous 2017 revision McDonald Criteria requires both dissemination in space and time to make a diagnosis of MS. The key update in the 2024 update is that either dissemination in space OR time is sufficient when combined with additional features listed below.
The key takeaway from the McDonald Criteria is that MS is typically characterised by dissemination in space and/or time reflected by the clinical presentation and supported by MRI and/or CSF findings.
The 2024 revised McDonald Criteria provides 2 diagnostic criteria.
| Disease presentation | MS diagnostic criteria |
|---|---|
| Typical MS presentation |
|
| Objective progression |
|
Management
General / Conservative Management
Modifiable risk factors for relapse and progression:
- Regular exercise may have beneficial effects
- Stop smoking
- Offer routinely recommended vaccinations
- Live vaccines should be avoided if patient is on immunosuppressive treatment
Acute Relapse Management
- 1st line: oral methylprednisolone 0.5g daily for 5 days
- Alternative: IV methylprednisolone 1g daily for 3-5 days
- Should be used if oral steroids failed / not tolerated, or patient admitted to hospital for a severe relapse
Diagnosing MS Relapse
Before diagnosing and treating relapse:
- Rule out infection (esp. UTI and RTI), and
- Discriminate between the relapse and fluctuations in disease or progression
Do not routinely diagnose a MS relapse if symptoms are present for >3 months
Long-Term Management (Disease-Modifying Therapy)
NICE guideline did not incorporate recommendations regarding disease-modifying therapies in NG220, instead, it provided a list of separate technology appraisals, see the full listings here.
Due to the above-mentioned reason, a summary of international EAN and AAN guidelines is deemed appropriate for exam purposes:
| MS Phenotype | Commonly used disease-modifying therapies |
|---|---|
| Clinically isolated syndrome (CIS) |
|
| Relapsing-remitting MS (RRMS) |
|
| Secondary progressive MS (SPMS) | |
| Primary progressive MS (PPMS) |
|
Complications Management
Disclaimer: this section focuses on three of the most common and clinically relevant MS symptoms, which NICE provides clear management strategies, and which are frequently encountered in both clinical practice and assessments. The remaining is deemed low-yield thus made redundant.
| Complication | Management | Notes |
|---|---|---|
| Fatigue | Non-pharmacological
Pharmacological (all off-label)
|
MS-related fatigue is very common, affecting up to 80% of patients |
| Spasticity | Consider referral to physiotherapy
Drug treatment
|
|
| Oscillopsia | Consider (all off-label)
|
Oscillopsia: subjective sensation that the environment is moving or bouncing |
MS and Pregnancy
- Impact on disease
- Pregnancy does not increase the risk of MS progression
- MS relapses may decrease during pregnancy and may increase 3 to 6 months after childbirth before returning to pre-pregnancy rates
- Impact on pregnancy and outcome
- Pregnancy can be well managed
- Risk of the child developing MS is slightly higher than average (but overall risk is low)
References
Original Guideline