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Updates to the MRI Protocol and Clinical Guidelines for MS: CMSC Working Group - Episode 4

Treatment Modifications Based on Inflammatory Activity

June Halper, MSN, APC-C, MSCN, FAAN: This gets me to the next concern or question. Scott, I would throw it at you is the new … criteria with inflammatory, active versus inactive, and the slides are excellent. But, in my opinion, I think it added to the confusion a bit because only the readers of the Journal of Neurology read it and then it gets out there, and patients are saying what am I? What’s happening?

Scott D. Newsome, DO, MSCS, FAAN: It’s hard when you start slicing and dicing things too much.

June Halper, MSN, APC-C, MSCN, FAAN: That’s right.

Scott D. Newsome, DO, MSCS, FAAN: I think in my view, and I’d certainly like to hear others’ point of views, is that when we’re looking at MS [multiple sclerosis] regardless if it’s relapsing or progressive disease, at least from the clinical standpoint in making treatment decisions and at least in my clinic, I’ll leverage a lot of my decisions on inflammatory activity or not. This is regardless of where you are in terms of the subtype. Where the guidelines are very helpful is the MRI [magnetic resonance imaging] guidelines specifically goes back to is there inflammation present or not? If there isn’t, then you have to step back and say, “OK, what are we going to do treatment wise? Am I going to escalate treatment even in the context of someone progressing clinically at the bedside, especially with the newer therapies that we have that have indications for progressive MS?

We have to always think about safety in mind with our patients and some of the newer drugs have quite a bit of baggage with them. It’s nice to have these subtypes and slicing and dicing, and categorizing people, but when it comes to disease modifying therapies, we have to look at if there is inflammatory activity or not. I think the MRI guidelines can help. I would say with the gadolinium topic that we’ve already discussed, that’s where for myself it’s a little more difficult. Even in the context of someone who’s had MS for a while, maybe I haven’t read a prescription to get contrast enhanced MRI. I see them having some worsening at the bedside, that might be an opportunity to do another contrasted MRI if they haven’t had 1 in a while to see if there was reactivation. Because, again, the presence of inflammatory versus noninflammatory activity is important.

June Halper, MSN, APC-C, MSCN, FAAN: Well, you in Canada and Europe have the much easier time. In the United States, we sometimes will see an authorization for an MRI. Only if you see activity then you can use gadolinium. You’ve seen that, right? It’s crazy.

Scott D. Newsome, DO, MSCS, FAAN: It’s very unusual. I guess the point is from the neuroradiologist side, I’d love to hear your view on this, for T2 lesions that are new, they were enhancing at some point, right? It’s just the timing of when you do MRIs.

Frederik Barkhof, MD, PhD: You just missed.

Scott D. Newsome, DO, MSCS, FAAN: You just missed it, right?

Frederik Barkhof, MD, PhD: You just missed it.

Scott D. Newsome, DO, MSCS, FAAN: I can understand the point of if you see a new lesion, doing a contrasted enhanced MRI after that, but it’s a new lesion regardless.

June Halper, MSN, APC-C, MSCN, FAAN: That’s right. Who’s going to read it? Neuroradiologists are not necessarily sitting there on site, so they’re asking the technician who’s doing the scan…

Frederik Barkhof, MD, PhD: Yeah, and that is not realistic. Ideally, you would look at the scan, I agree, and if there are no changes there’s also no need to give gadolinium. But how confident are you? In a real-time read at the monitor, not in your reporting room, I think that’s a difficult one and also will be obstructive in terms of patient throughput. Every time the radiologist has to come in the room, look at the scans, review them, and then decide to give gadolinium. So if they don’t, there is an empty slot, or if you have the next patient waiting and then suddenly you have to do the gadolinium scan, I don’t think that’s a workable situation.

David Li, MD, FRCPC: I think one of the things we’ve talked about at this meeting, and also in prior meetings, was emphasizing the point that that communication between the neurologist and the radiologist in terms of requesting that study needs to indicate whether the neurologist is looking for current activity. If they’re looking for current activity, then gadolinium is very important because it tells you that there is a new activity that has happened within the past 4 weeks. On the other hand, if what they’re interested in is what’s happened during the time from their last visit, say a year ago, whether there’s been any new activity. Certainly, the T2 scan by itself is all that is necessary. It’s not necessary to give a gadolinium examination. The distinguishing feature is whether from their point of view in terms of their deciding with a patient, whether it needs to initiate treatment or modify treatment, whether that need to know whether the activity is ongoing currently or whether it’s happened during that.

Frederik Barkhof, MD, PhD: That’s why it’s important to have sufficient information on the request form.

June Halper, MSN, APC-C, MSCN, FAAN: Exactly.

Frederik Barkhof, MD, PhD: Quite often, to be honest, it says monitoring therapy. Well, OK, so what is your goal?

June Halper, MSN, APC-C, MSCN, FAAN: Why, yeah.

Frederik Barkhof, MD, PhD: If it’s just a routine monitoring, you know the anticipated result is that it’s negative, nothing happened, and then you can do that without gadolinium. If there is concern about possible activity or you’re considering switching, put it on a request form because that will trigger us to give gadolinium. That’s an important decision point.

Scott D. Newsome, DO, MSCS, FAAN: Oh, I think that’s a great point because just saying MS…

Frederik Barkhof, MD, PhD: MS, monitoring, yeah.

June Halper, MSN, APC-C, MSCN, FAAN: No, you’re right and maybe that should be in the printed guideline when we print it up. We should have a sample way of requisitioning the MRI because that would help the clinician who is not exposed to this type of information. I really think that would be something we should put as a high priority. It would enhance our message.