title: Therapeutic approaches to disease modifying therapy for multiple sclerosis in adults: an Australian and New Zealand perspective: part 3 treatment practicalities and recommendations. MS Neurology Group of the Australian and New Zealand Association of Neurologists.
abstract: In this third and final part of our review of multiple sclerosis (MS) treatment we look at the practical day-to-day management issues that are likely to influence individual treatment decisions. Whilst efficacy is clearly of considerable importance, tolerability and the potential for adverse effects often play a significant role in informing individual patient decisions. Here we review the issues surrounding switching between therapies, and the evidence to assist guiding the choice of therapy to change to and when to change. We review the current level of evidence with regards to the management of women in their child-bearing years with regards to recommendations about treatment during pregnancy and whilst breast feeding. We provide a summary of recommended pre- and post-treatment monitoring for the available therapies and review the evidence with regards to the value of testing for antibodies which are known to be neutralising for some therapies. We review the occurrence of adverse events, both the more common and troublesome effects and those that are less common but have potentially much more serious outcomes. Ways of mitigating these risks and managing the more troublesome adverse effects are also reviewed. Finally, we make specific recommendations with regards to the treatment of MS. It is an exciting time in the world of MS neurology and the prospects for further advances in coming years are high.
authors.affiliation: School of Medicine, Griffith University, Gold Coast Campus, QLD 4222, Australia; Department of Neurology, Gold Coast University Hospital, Southport, QLD, Australia. Electronic address: simon.broadley@griffith.edu.au.
authors.forename: Simon A
authors.initials: SA
authors.lastname: Broadley
authors.affiliation: Brain and Mind Research Institute, University of Sydney, Camperdown, NSW, Australia.
authors.forename: Michael H
authors.initials: MH
authors.lastname: Barnett
authors.affiliation: Department of Neurology, The Townsville Hospital, Douglas, QLD, Australia.
authors.forename: Mike
authors.initials: M
authors.lastname: Boggild
authors.affiliation: Department of Neurology and St Vincent's Centre for Applied Medical Research, St Vincent's Hospital, University of New South Wales, Darlinghurst, NSW, Australia.
authors.forename: Bruce J
authors.initials: BJ
authors.lastname: Brew
authors.affiliation: Melbourne Brain Centre, Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia; Department of Neurology, Eastern Health and Monash University, 2/5 Arnold Street, Box Hill VIC 3128, Australia.
authors.forename: Helmut
authors.initials: H
authors.lastname: Butzkueven
authors.affiliation: Westmead Clinical School, University of Sydney, NSW, Australia.
authors.forename: Robert
authors.initials: R
authors.lastname: Heard
authors.affiliation: South Western Sydney Clinical School, University of New South Wales, NSW, Australia.
authors.forename: Suzanne
authors.initials: S
authors.lastname: Hodgkinson
authors.affiliation: Centre for Neuromuscular and Neurological Disorders, University of Western Australia, WA, Australia.
authors.forename: Allan G
authors.initials: AG
authors.lastname: Kermode
authors.affiliation: Hunter Medical Research Institute, The University of Newcastle, New Lambton, NSW, Australia.
authors.forename: Jeannette
authors.initials: J
authors.lastname: Lechner-Scott
authors.affiliation: Department of Neurology, Austin Health, Heidelberg, VIC, Australia.
authors.forename: Richard A L
authors.initials: RA
authors.lastname: Macdonell
authors.affiliation: Melbourne Brain Centre, Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia.
authors.forename: Mark
authors.initials: M
authors.lastname: Marriott
authors.affiliation: Department of Neurology, Christchurch Hospital, Christchurch, New Zealand.
authors.forename: Deborah F
authors.initials: DF
authors.lastname: Mason
authors.affiliation: Central Clinical School, University of Sydney, NSW, Australia.
authors.forename: John
authors.initials: J
authors.lastname: Parratt
authors.affiliation: Brain and Mind Research Institute, University of Sydney, Camperdown, NSW, Australia.
authors.forename: Stephen W
authors.initials: SW
authors.lastname: Reddel
authors.affiliation: School of Medicine, Deakin University, VIC, Australia.
authors.forename: Cameron P
authors.initials: CP
authors.lastname: Shaw
authors.affiliation: Flinders Medical Centre, Flinders University, SA, Australia.
authors.forename: Mark
authors.initials: M
authors.lastname: Slee
authors.affiliation: Brain and Mind Research Institute, University of Sydney, Camperdown, NSW, Australia.
authors.forename: Judith
authors.initials: J
authors.lastname: Spies
authors.affiliation: Menzies Research Institute, University of Tasmania, TAS, Australia.
authors.forename: Bruce V
authors.initials: BV
authors.lastname: Taylor
authors.affiliation: Centre for Neuromuscular and Neurological Disorders, University of Western Australia, WA, Australia.
authors.forename: William M
authors.initials: WM
authors.lastname: Carroll
authors.affiliation: Menzies Research Institute, University of Tasmania, TAS, Australia.
authors.forename: Trevor J
authors.initials: TJ
authors.lastname: Kilpatrick
authors.affiliation: Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, VIC, Australia.
authors.forename: John
authors.initials: J
authors.lastname: King
authors.affiliation: University of Queensland Centre for Clinical Research, QLD, Australia.
authors.forename: Pamela A
authors.initials: PA
authors.lastname: McCombe
authors.affiliation: Brain and Mind Research Institute, University of Sydney, Camperdown, NSW, Australia.
authors.forename: John D
authors.initials: JD
authors.lastname: Pollard
authors.affiliation: Department of Neurology, Auckland City Hospital, Auckland, New Zealand.
authors.forename: Ernest
authors.initials: E
authors.lastname: Willoughby
mesh_terms: D000328:Adult; D061067:Antibodies, Monoclonal, Humanized / Q000009:adverse effects / Q000276:immunology / Q000627:therapeutic use; D001315:Australia / Q000453:epidemiology; D019468:Disease Management; D018450:Disease Progression; D016903:Drug Monitoring; D057915:Drug Substitution; D064420:Drug-Related Side Effects and Adverse Reactions / Q000209:etiology / Q000517:prevention & control; D019317:Evidence-Based Medicine; D005260:Female; D005544:Forecasting; D006801:Humans; D007166:Immunosuppressive Agents / Q000009:adverse effects / Q000627:therapeutic use*; D016899:Interferon-beta / Q000276:immunology / Q000627:therapeutic use; D007577:JC Virus / Q000276:immunology / Q000302:isolation & purification; D007774:Lactation; D007968:Leukoencephalopathy, Progressive Multifocal / Q000517:prevention & control; D008297:Male; D009103:Multiple Sclerosis / Q000188:drug therapy* / Q000453:epidemiology / Q000473:pathology / Q000628:therapy; D000069442:Natalizumab; D009500:Neutralization Tests; D009520:New Zealand / Q000453:epidemiology; D011247:Pregnancy; D011248:Pregnancy Complications / Q000188:drug therapy; D035703:Therapies, Investigational / Q000639:trends*; D016896:Treatment Outcome
chemical_list: D061067:Antibodies, Monoclonal, Humanized; D007166:Immunosuppressive Agents; D000069442:Natalizumab; D016899:Interferon-beta
keywords: Evidence-based medicine; Guideline; Multiple sclerosis; Review; Treatment