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Multiple Sclerosis — Written Clinical Reasoning
DCE long-case preparation: structured written reasoning for multiple sclerosis — the clinical course (RRMS 85 per cent, SPMS, PPMS 15 per cent), the McDonald 2017 diagnostic criteria (dissemination in space and time, CSF oligoclonal bands), the DMT landscape (interferon, glatiramer, dimethyl fumarate, fingolimod, cladribine, siponimod, natalizumab with PML risk, ocrelizumab for PPMS and RRMS, alemtuzumab), acute relapse management (methylprednisolone, plasma exchange), symptom management, and pregnancy planning (washout, PRIMS relapse pattern, breastfeeding).
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Multiple Sclerosis — Written Clinical Reasoning
SAQ — Highly active RRMS failing interferon: DMT escalation (30 marks, 45 minutes)
Prompt: Work through the diagnosis and disease activity assessment, a DMT escalation strategy with risk-benefit analysis, monitoring, acute relapse and symptom management, reproductive planning, and exclusion of mimics for this patient. Justify each decision with reference to evidence. [1]
Case vignette: A 29-year-old woman with relapsing-remitting MS has had four relapses in 18 months despite interferon beta-1a, with incomplete recovery (EDSS 3.5) and 3 gadolinium-enhancing lesions on MRI. JC virus antibody positive (index 1.8). AQP4-IgG and MOG-IgG negative. She plans pregnancy within 2 years. [1]
References10ShowHide
- [1]Thompson AJ, Banwell BL, Barkhof F, et al. Diagnosis of multiple sclerosis: 2017 revisions of the McDonald criteria Lancet Neurol, 2018.PMID 29275977
- [2]Lublin FD, Reingold SC, Cohen JA, et al. Defining the clinical course of multiple sclerosis: the 2013 revisions Neurology, 2014.PMID 24871874
- [3]Bjornevik K, Cortese M, Healy BC, et al. Longitudinal analysis reveals high prevalence of Epstein-Barr virus associated with multiple sclerosis Science, 2022.PMID 35025605
- [4]Montalban X, Hauser SL, Kappos L, et al. Ocrelizumab versus Placebo in Primary Progressive Multiple Sclerosis N Engl J Med, 2017.PMID 28002688
- [5]Hauser SL, Bar-Or A, Comi G, et al. Ocrelizumab versus Interferon Beta-1a in Relapsing Multiple Sclerosis N Engl J Med, 2017.PMID 28002679
- [6]Kappos L, Bar-Or A, Cree BAC, et al. Siponimod versus placebo in secondary progressive multiple sclerosis (EXPAND): a double-blind, randomised, phase 3 study Lancet, 2018.PMID 29576505
- [7]Bloomgren G, Richman S, Hotermans C, et al. Risk of natalizumab-associated progressive multifocal leukoencephalopathy N Engl J Med, 2012.PMID 22591293
- [8]Confavreux C, Hutchinson M, Hours MM, et al. Rate of pregnancy-related relapse in multiple sclerosis. Pregnancy in Multiple Sclerosis Group N Engl J Med, 1998.PMID 9682040
- [9]Cohen JA, Coles AJ, Arnold DL, et al. Alemtuzumab versus interferon beta 1a as first-line treatment for patients with relapsing-remitting multiple sclerosis: a randomised controlled phase 3 trial Lancet, 2012.PMID 23122652
- [10]Coles AJ, Twyman CL, Arnold DL, et al. Alemtuzumab for patients with relapsing multiple sclerosis after disease-modifying therapy: a randomised controlled phase 3 trial Lancet, 2012.PMID 23122650