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LP, brain and spinal cord MRI are ancillary tests for RIS investigation.
DMT should not be initiated if T2/FLAIR lesions alone are seen in brain MRI, and a follow-up MRI should be requested in six months.
DMT should be considered if the follow-up examination demonstrates any Gd+ lesion or if the patient presents any clinical symptom suggestive of relapse.
9 CIS 5
LP, brain and spinal cord MRI are ancillary tests for CIS investigation.
DMT should not be initiated if the only abnormality in the investigative examination is partial myelitis or optic neuritis, and a follow-up MRI should be requested in three or six months.
DMT should be considered in CIS patients with high risk of conversion to MS.
DMT should be considered if MRI demonstrates Gd+ lesions (unless the topography is the optic nerve). In case of optic neuritis, DMT should be initiated if the MRI and CSF demonstrate spatial dissemination and oligoclonal bands, respectively.
: RRMS ~
LP is an ancillary test for RRMS investigation.
DMT should be initiated for a treatment-naïve patient with mild disease (few hyperintense lesions on T2/FLAIR, no Gd+ lesions and low annual rate of clinical relapse), preferably a first-line therapy (injectable or oral drugs), and a follow-up MRI should be requested in six months.
An increase in case severity (atrophy, black holes, new lesions on MRI, or two or more clinical relapses in 12 months) saw a preference for switching therapy to a more effective DMT, such as third-line or fourth-line intravenous drugs.
The only DMT more broadly indicated for continuation during pregnancy is GA.
L Therapeutic management
DMT switching should be considered in situations of occurrence of 1-2 clinical relapses, 1-5 new or enlarging T2/FLAIR lesions, or a minimum of one Gd+ lesion on MRI, in a 12-month period.
A wash-out period is considered for some DMT escalation, such as to alemtuzumab, cladribine, cyclophosphamide, mitoxantrone, natalizumab, fingolimod, ocrelizumab and rituximab. No wash-out period is needed for IFN and GA treatments.
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