Advances in the treatment of multiple sclerosis have been good news for patients, but side- effects and risks mean that active management strategy and constant monitoring are essential, advise the authors of a Clinical Focus published online by the Medical Journal of Australia.

The authors, including Professor Simon Broadley from the Griffith University School of Medicine on the Gold Coast, warned that "most of the newer, more effective therapies are associated with risks and practical problems that necessitate an active management strategy and continuous vigilance".

"All current treatments for MS have some minor side effects and several of the more potent agents are associated with specific risks that need to be managed", they wrote.

"It is important to remain vigilant to potential late complications with some of the newer therapies." Three particular problems were:

  • Progressive multifocal leukoencephalopathy (PML), caused by infection of the brain with the widespread but normally innocuous JC virus, typically develops in patients with an immunodeficiency or undergoing immunosuppressive therapy. "PML has been extensively documented in patients with MS treated with natalizumab, and there have been case reports associated with dimethyl fumarate and fingolimod", the authors wrote. "Caution is warranted when using these drugs in any patients who are JC virus antibody-positive."
  • Autoimmune disease can develop between 1 and 5 years after commencing treatment with alemtuzumab. "Continual vigilance for the symptoms of these complications is required and, perhaps more importantly, regular laboratory testing, including full blood counts each month for at least 5 years. If detected early, these conditions respond to standard therapies, but they can emerge quite precipitately and should be treated urgently."
  • Lymphopenia and deranged liver function tests can be caused to varying degrees by almost all the available therapies, Broadley and colleagues note. "Repeat testing and possibly the cessation of therapy are appropriate if significant deviations from normal values [occurs] ... Therapy should be stopped immediately if a higher degree of abnormality is detected."

Monitoring for compliance was also vital, considering the long-term nature of MS therapies.

The authors concluded that: "General practitioners and specialist physicians need to be aware of the potential complications and specific features of MS therapies, particularly in rural and remote settings where rapid access to specialist neurological services may not be available."

"It is evident that the indications for therapy and the [current] recommendations are not entirely consistent with one another, and that there is an urgent need for the current restrictions on prescribing MS therapies to be adjusted in the light of new evidence."

There is nevertheless reason for optimism: "While a cure for MS remains elusive, the potential to reduce inflammatory disease activity by preventing relapses and minimising disease progression is achievable."