Highly Aggressive Multiple Sclerosis

James D. Bowen, MD Multiple Sclerosis and Other CNS Inflammatory Diseases p. 689-714 June 2019, Vol.25, No.3 doi: 10.1212/CON.0000000000000731
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PURPOSE OF REVIEW: Newly introduced disease-modifying therapies offer greater efficacy than previous therapies but also have serious side effects. This article reviews factors useful in identifying those at risk of developing aggressive relapsing multiple sclerosis (MS) and therapies available for treatment.

RECENT FINDINGS: Several factors predict aggressive MS, including demographic factors, relapses, symptom characteristics, MRI activity, and other biomarkers. These can be used to select patients for more aggressive therapies, including natalizumab, alemtuzumab, fingolimod, and ocrelizumab. Additional off-label treatments are available for patients with severe disease. The benefits and side effects of these treatments must be considered when making therapeutic decisions.

SUMMARY: Selecting patients who are most appropriate for aggressive therapy involves considering risk factors for poor outcomes, early recognition of treatment failure, balancing treatment efficacy and side effects, and sharing the decision with patients to assist them in making optimal treatment choices. Vigilance for signs of treatment failure and early switching to more aggressive therapy are important components in optimal care.

Address correspondence to Dr James D. Bowen, Multiple Sclerosis Center, Swedish Neuroscience Institute, 1600 E Jefferson St, Ste A, Seattle, WA 98122, james.bowen@swedish.org.

RELATIONSHIP DISCLOSURE: Dr Bowen has served as a consultant for Biogen; Celgene Corporation; EMD Serono, Inc; Genentech, Inc; and Novartis AG and has received personal compensation for speaking engagements from Biogen; EMD Serono, Inc; Genentech, Inc; and Novartis AG. Dr Bowen receives research/grant support from Alexion; Alkermes; Biogen; Celgene Corporation; Genentech, Inc; the National Institute of Allergy and Infectious Diseases (UM1AI110557); the National Institutes of Health/National Institute on Aging (U01AG006781); the National Institutes of Health/National Institute of Allergy and Infectious Diseases (N01AI15416); the National Institute of Neurological Disorders and Stroke (U10NS077309); and Sanofi Genzyme.

UNLABELED USE OF PRODUCTS/INVESTIGATIONAL USE DISCLOSURE: Dr Bowen discusses the unlabeled/investigational use of cyclophosphamide, high-dose immunosuppressive therapy with stem cell transplantation, and rituximab for the treatment of highly aggressive multiple sclerosis.

© 2019 American Academy of Neurology.