Monitoring
The frequency of monitoring for patients with MS depends on the status of the patient.
Patients who are experiencing a relapse should be seen by their healthcare provider at the time of the relapse or soon after to determine if there is any need for acute management, and to assess the impact of the relapse on their choice of ongoing therapy.
Most patients need to be seen only every 6 to 12 months if they are relatively stable and not requiring medication changes in either their symptomatic or disease-modifying therapy.
Some practitioners obtain timed 25-foot walk (T25FW) and 9-hole peg tests as quantitative measures of functioning that allows for comparison from visit to visit.[214] The minimally important clinical difference for improvements in the T25FW test is estimated to be 20% for patients with MS.[215]
MS-specific patient-reported outcomes
Patient-reported outcomes (PRO) specific to MS have been identified. The evaluation of more than 80 PRO tools specific for MS supports the use of the Multiple Sclerosis Impact Scale (MSIS-29; measures the physical and psychological impact of MS) and the Leeds Multiple Sclerosis Quality of Life scale (LMSQOL). However, one systematic review concluded that new MS instruments specific to primary progressive MS and secondary progressive MS populations are needed.[216]
Ongoing laboratory evaluation
Patients with MS have a higher incidence of diabetes and of vitamin B12, vitamin D, and thyroid deficiencies than the general population, and should have appropriate blood work performed to screen for those conditions on occasion, particularly in patients with fatigue.
The need for further monitoring blood work depends on the disease-modifying agent used.
No monitoring is required for glatiramer. Patients on interferons, fingolimod, and natalizumab should have complete blood count and liver function tests checked every 3 to 6 months. John Cunningham virus (JCV) antibody titer testing should also be undertaken at baseline for patients on natalizumab. Expert panel recommendations regarding the stratification and ongoing monitoring of natalizumab-associated progressive multifocal leukoencephalopathy risk have been published.[102]
Immunosuppressive agents such as methotrexate and azathioprine require frequent monitoring of liver function and blood counts. For patients on fingolimod, monitoring should include repeat ophthalmologic exam 3 to 4 months after initiating treatment. Patients should also be monitored closely for evidence of exacerbation of MS after stopping fingolimod treatment.[95]
Alemtuzumab requires monthly blood and urine monitoring for 48 months after the last infusion through a stringent risk evaluation and mitigation strategy.
The clinical and radiographic impact of neutralizing antibodies to interferon beta-1b is still unclear.[217]
Magnetic resonance imaging (MRI) surveillance
An MRI brainshould be obtained 3 to 6 months after initiation or switching of disease-modifying therapy; a longer interval may be considered for patients treated with slow-acting disease-modifying therapy. The same protocol should be used as for the baseline MRI.[3]
An annual MRI is recommended in clinically stable patients to monitor for new disease activity; imaging should be performed more frequently if there are concerns.[3][218]
MRI is also used to monitor for complications of treatment, such as progressive multifocal leukoencephalopathy.[3]
Spinal imaging for monitoring should be considered in patients with a spinal cord phenotype (few brain lesions), repeated spinal cord relapse, or progressive disability that cannot be explained by MRI brain findings.[3] Spinal cord MRI is not recommended for routine follow-up monitoring of disease activity in other patients with MS.
The need for MRI for monitoring during pregnancy should be assessed on a case-by-case basis; e.g., it may be appropriate for a patient with unexpected disease activity. Gadolinium-based contrast agents are contraindicated during pregnancy.[3]
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