With the commitment to so-called Evidence-based Medicine (EBM = “medicine based on empirical evidence”), therapy guidelines as scientifically founded, practice-oriented recommendations play a significant role. Guidelines represent the current state of a subject area based on clinical studies and medical publications that confirm or refute a fact. The new guidelines for the treatment of Multiple Sclerosis have now been published.The last version of the guidelines for the treatment of Multiple Sclerosis dates back to 2014. In the meantime, a lot has happened, which is why a new version of the guidelines was eagerly awaited and posted online on May 17, 2021. For us neurologists, the therapy guidelines are of great interest. This is certainly one reason for the great anticipation and critical commentary. From a patient’s perspective, I’m not even sure whether the detailed explanations are actually of such great importance. On the other hand, it is certainly not uninteresting for patients to inform themselves about the current state of science and the resulting decision and action options in MS. Therefore, here for all interested parties is the link to the new guidelines for the treatment of Multiple Sclerosis on the pages of the German Society for Neurology.
Guidelines as a guardrail
The current guidelines are a so-called S2K guideline. A consensus-based (k) guideline is the consensus of multidisciplinary expert groups on certain procedures in medicine, taking into account the best available evidence. This explains, on the one hand, the long process of creating the guideline. And on the other hand, it makes clear that the guideline is not a concrete instruction for action, but rather a guardrail for the therapy of Multiple Sclerosis. The implementation lies in the discretion of the practitioner in the case-specific consideration.
And from the point of view of many practitioners, the current version of the guideline has not only aroused undivided enthusiasm – especially with regard to the part of immunotherapy. Nevertheless, great recognition should be given to the authors at this point for their careful and comprehensive processing of the subject matter over more than 200 pages.
Tripartite division of immunotherapeutics
The criticism mainly refers to a tripartite division of the available immunotherapeutics into different efficacy levels, which cannot be unambiguously justified by the scientific data situation. In addition, the classification results in a contradiction with the official approval for some active ingredients. Furthermore, there is concern that the tripartite division of the available drugs suggests to the neurologist less experienced with MS that one has to “work through” the different efficacy levels of the immunotherapies one after the other. This could cause unnecessary time to be lost, especially in more active and more severely affected MS patients, before sufficiently potent therapy is started.
Another point of criticism is the rather marginal discussion of the concept of pulsed immunotherapy, although this can have great advantages for patients, especially in the early stages of the disease. The defensive attitude towards early therapy for Multiple Sclerosis and the rather generous evaluation of discontinuing immunotherapy also led to criticism.
Since I personally often suggest an active therapeutic approach and consider the risk of “overtherapy” in MS to be low, I would have preferred a more aggressive and proactive German guideline. This would also be more in line with the European guideline (ECTRIMS/EAN 2018) and most international professional societies. They represent the view that long-term stabilization of the disease, possibly even a reduction in disease severity, can be achieved by using highly effective therapies if the inflammation is stopped as early and as completely as possible.
Another note on my own behalf:
