Clinical Practice in the USA

Tornatore et al. Practice patterns of US neurologists in patients with CIS, RRMS, or RIS: A consensus study Neurol Clin Pract March 2012 2:48-57
We assess current practice patterns of US neurologists in MSers with clinically isolated syndrome (CIS), relapsing-remitting multiple sclerosis (RRMS), and radiologically isolated syndrome (RIS) using case-based surveys. For CIS, 87% recommended initiation of disease-modifying therapy (DMT) with MRI brain lesions. An injectable DMT was recommended by 90%–98% for treatment-naive, mild RRMS patients. There was 97% consensus to treat highly active RRMS, but no consensus on therapy choice. With RIS, there was consensus not to initiate treatment with brain but no spinal MRI lesions. Current US treatment patterns emphasize MRI in MS diagnosis and subsequent treatment decisions, treatment of early disease, aggressive initial treatment of highly active MS, and close MSer monitoring.



Khan et al. Practice patterns of US neurologists in patients with SPMS and PPMS:A consensus study Neurol Clin Pract March 2012 2:58-66
A modified Delphi process assessed current multiple sclerosis (MS) practice patterns for secondary and primary progressive MS (secondary progressive MS [SPMS] and primary progressive MS [PPMS]). In early 2011, 2 sequential, case-based surveys were administered to 75 US MS specialists to assess treatment practices and patient management. Respondents were from geographically diverse US academic (42%) and community (58%) treatment centers. There was consensus (≥75% agreement in responses) to switch disease-modifying therapies for an MSer with SPMS with both MRI activity and disability progression (95%), but no consensus on treatment selection. For PPMS, responses supported diagnosis using spinal MRI (100%) and lumbar puncture (75%) and treatment initiation in patients with brain gadolinium-enhancing lesions with or without spinal cord lesions (85%); however, there was no consensus on treatment initiation with spinal cord lesions alone or initial therapy. The lack of agreement among US MS experts on the best treatment approaches for SPMS or PPMS highlights the need for effective therapies



"Although we are based in the UK, many of our readers are based in the USA, hence this post. In the UK we are not able to prescribe DMTs so liberally. Our current guidelines don't allow us to use DMTs in CIS and we can only use them in a minority of MSers with RRMS. A person with RRMS has to fulfil contemporary criteria for having active disease, i.e. two significant attacks in a 2 year period.  Finally, we can only prescribe natalizumab, and now fingolimod, for MSers with highly active relapsing MS: two disabling attacks in a 12 month period with MRI evidence of active disease (new lesions or Gd-enhancing lesions). These factors, and the fact that UK MSologists are more conservative than US MSologists, explains the low rate of DMT penetration in the UK compared to the US. In the UK less than 1 in 4 MSers are on a DMT compared to over 3 in 4 MSers in the US. Are we being too conservative?"

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