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Neurology. 2018 Apr 24;90(17):777-788. doi: 10.1212/WNL.0000000000005347.

Practice guideline recommendations summary: Disease-modifying therapies for adults with multiple sclerosis: Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology.

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From the Department of Neurology (A.R.-G.), Cleveland Clinic, OH; Department of Neurology (G.S.D.), Charles F. and Joanne Knight Alzheimer Disease Research Center, Washington University in St. Louis, MO; Department of Community Health Sciences (R.A.M.), Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada; Department of Neurology (A.R.), Mayo Clinic, Rochester, MN; UCSF Weill Institute for Neurosciences, Department of Neurology (B.A.C.C.), University of California, San Francisco; Department of Neurology (G.S.G.), Kansas University Medical Center, Kansas City; Department of Neurology (M.H.), School of Medicine, University of Louisville, KY; Consortium of Multiple Sclerosis Centers (J.H.), Hackensack, NJ; Department of Neuroscience (J.P.H.), St. Luke's University Health Network, Bethlehem, PA; Department of Neurology (D.E.J.), University of Virginia, Charlottesville; Consortium of Multiple Sclerosis Centers (R.L.), Hackensack, NJ; Department of Neurology (R.L.), School of Medicine, Wayne State University, Detroit, MI; Department of Neurology (D.P.), Keck School of Medicine, University of Southern California; Neurology Department (S.P.), Southern California Permanente Medical Group, Kaiser, Los Angeles; National Multiple Sclerosis Society (C.S.), Arlington, VA; National Multiple Sclerosis Society (R.S.), New York, NY; Santa Fe (J.S.), NM; Heart Rhythm Society (T.S.D.G.), Washington, DC; American Academy of Neurology (S.A.M.), Minneapolis, MN; and Department of Clinical Neurosciences, Psychiatry, Pediatrics and Community Health Sciences, Cumming School of Medicine (T.P.), University of Calgary, Alberta, Canada.



To develop recommendations for disease-modifying therapy (DMT) for multiple sclerosis (MS).


A multidisciplinary panel developed DMT recommendations, integrating findings from a systematic review; followed an Institute of Medicine-compliant process to ensure transparency and patient engagement; and developed modified Delphi consensus-based recommendations concerning starting, switching, and stopping DMTs pertinent to people with relapsing-remitting MS, secondary progressive MS, primary progressive MS, and clinically isolated syndromes of demyelination. Recommendations were supported by structured rationales, integrating evidence from one or more sources: systematic review, related evidence (evidence not from the systematic review), principles of care, and inference from evidence.


Thirty recommendations were developed: 17 on starting DMTs, including recommendations on who should start them; 10 on switching DMTs if breakthrough disease develops; and 3 on stopping DMTs. Recommendations encompassed patient engagement strategies and individualization of treatment, including adherence monitoring and disease comorbidity assessment. The panel also discussed DMT risks, including counseling about progressive multifocal leukoencephalopathy risk in people with MS using natalizumab, fingolimod, rituximab, ocrelizumab, and dimethyl fumarate; and made suggestions for future research to evaluate relative merits of early treatment with higher potency DMTs vs standard stepped-care protocols, DMT comparative effectiveness, optimal switching strategies, long-term effects of DMT use, definitions of highly active MS, and effects of treatment on patient-specified priority outcomes. This guideline reflects the complexity of decision-making for starting, switching, or stopping MS DMTs. The field of MS treatment is rapidly changing; the Academy of Neurology development process includes planning for future updates.

[Indexed for MEDLINE]

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