Relapse in Multiple Sclerosis: A New Algorithm for Treatment


Stephen Krieger, MD: We’ve already talked about how we think about relapses, how we assess them in principle, and the goals of treatment. But why don’t we turn to the new white paper that you’re presenting at the CMSC [Consortium of Multiple Sclerosis Centers Annual] Meeting in 2019, which is a new algorithm to try to standardize how it’s recommended to do this, drawing from some of these best practices in a way that is implementable for anyone who takes care of people with MS. Tell us a little bit about this white paper, this optimizing MS [multiple sclerosis]—relapse management-structured approach that you’re presenting at the CMSC meeting.

Amy Perrin Ross, APN, MSN, CNRN, MSCN: As you know, I mean there were several of us who are here who participated in this labor of love, shall we say. And actually, if I think about it, Steve, it goes back a number of years ago, when several of my colleagues and friends from North America—Canada and the United States—were sitting around talking about relapses and people who tell us they have 3 relapses a day and some of those things and what our challenges and frustrations were. One of the things we did was convene a group of peers, a small group, and develop something called the ARMS [Assessing Relapse in Multiple Sclerosis] tool, which was an assessment of relapses in MS. We actually had many back-and-forths, as you can imagine, trying to figure out what we could get to fit on 1 page that was pertinent to a relapse assessment, because we felt clinicians didn’t want any more than 1 page.

We finally came to a consensus. We piloted it. We tested it for reliability and validity. We were able to assess those measures, and it’s been put into practice, and it’s available to anyone who wants to use it. And it looks at assessing relapses and going through much of the discussion we’ve already had this morning. Fast-forward to the last year or so, a group of physician colleagues and advanced practice colleagues were convened to put together potentially a tool, as you said, or an algorithm that could help guide us. And guide us well, people like us who live and breathe MS every single day have our own nuances and our own ways of doing things with patients. But we were hoping that this algorithm is something that can be useful beyond just the big MS centers. Because as we know, 66% of people with MS do not get their regular care at an MS center. They’re out somewhere.

The algorithm has basically 3 steps. It starts with evaluating the symptoms, just as we have talked about, potential use of an MRI [magnetic resonance imaging test] if and when it’s needed. Then we move into step 2, which is looking at managing the relapse, and I think we’re going to talk a little bit about approaches to managing, who uses what, how we make decisions, and where that fits in the grand scheme of things. And then finally step 3 is assessing the outcomes. We can go right back to that ARMS tool, because the second half of the ARMS tool is a 1-month evaluation assessing the outcome of whatever was done to manage that relapse. And in some cases, what was done to manage that relapse was watch and wait. So we go back and we take a look at that, and that’s all set forth in an algorithm. And again, I’ll be presenting that later this afternoon.

Stephen Krieger, MD: The idea there is that it’s not enough to just evaluate the symptoms and treat. It’s not enough to treat and not reevaluate again. But it’s really this 3-step process of have a goal, as Sam talked about, the rationale for treatment, trying to shut down the inflammation that’s there; use a strategy to treat the relapse, and we’re going to talk about those momentarily; and then reassess and see whether that person has actually gotten back to their baseline, as best we can assess, to see whether there’s still disability or changes that are evolving that may need further treatment. Or if we’ve held off on treatment, they may then need treatment. So it really, all 3 parts of that structured approach I think are pretty essential.

Amy Perrin Ross, APN, MSN, CNRN, MSCN: The ARMS tool is useful in a couple of ways. If you think about it, Rob was talking about the virtual visits, we can give these, this 1-page tool, to our patients while they’re sitting in the waiting room. We could do it over a phone to help us decide if it’s worth for them to drive the 200 miles to come in and see us for this evaluation, or maybe not. And there’s lots of ways to use that assessment tool. We could bring the patients in if we had that luxury, but it’s really meant to be done over the phone, so we have an idea of what our next step needs to be so we just don’t drop the ball after 1 course of steroids.

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