Edited by: Zsolt Illes, University of Southern Denmark Odense, Denmark
Reviewed by: Robert Weissert, University of Regensburg, Germany
Specialty section: This article was submitted to Multiple Sclerosis and Neuroimmunology, a section of the journal Frontiers in Neurology
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The former (
We suggest the introduction of a FAST into the clinical practice of MS. This tool aims at supporting neurologists in monitoring and treating MS patients. It recognizes the achievements of the former and current MS classifications and includes additional patient- and disease-related information in a five-dimensional structure to inform the clinician and deliver the necessary arguments for therapy selection. FAST has been partially inspired by a five-dimensional patient-oriented classification in epileptic patients (
The first dimension of FAST is defined as “phenotype.” Here, we retain the already well-established MS phenotypes [“relapse-remitting,” “secondary progressive,” “primary progressive,” and “clinically isolated syndrome” (CIS)]. Although a “radiologically isolated syndrome” (RIS) has not been recognized as a distinct MS syndrome (
“Disease dynamics” represents the second dimension of FAST. Besides the current Expanded Disability Status Scale (EDSS), three well-known modifiers from the present MS classification (
The third dimension of FAST comprises individual findings, which have led to the diagnosis of CIS or MS. This includes the time point of first symptom occurrence, the time point of first diagnosis, information about the McDonald/MAGNIMS criteria (
The fourth dimension, “DMT,” covers the history of DMTs received by the patient, including the current one. It informs the clinician about the individual dynamics of the disease, both clinically and on imaging modalities, and thus indirectly points to the patient-related efficacy of the respective treatment. Furthermore, it may help to recognize patterns of responsiveness to B- or T-cell directed DMTs. Relevant parameters for surveillance of the current DMT like anti-JC virus antibody serum levels or lymphocyte count can be integrated in this dimension, enabling a more stringent monitoring of therapy-associated risks.
The fifth dimension, “related medical conditions,” describes individual aspects that influence the therapeutic decision or suggest a specific surveillance of the patient. Among others, this includes family planning as well as diseases relevant in the context of certain DMTs like liver cirrhosis, hyperthyroidism, and renal insufficiency. Careful consideration of the information represented in this final dimension would allow the clinician to choose the DMT with the least side effects and risks for this patient.
To demonstrate the benefits of FAST in the clinical context, we present an excerpt from an extensive medical report on a fictive MS patient who seeks a second opinion about escalation of her DMT. After having read the medical history, the reader may compare it directly with the content of Table
On the left side of the table are the five dimensions of FAST with the available options which the clinician can choose between (e.g., “Phenotype” can be “relapse-remitting,” “secondary progressive,” etc.) and the different subdimensions [e.g., “Disease dynamics” is defined by information about the current Expanded Disability Status Scale (EDSS), activity, progression, and worsening].
Relapse-remitting disease Secondary progressive disease Primary progressive disease Clinically isolated syndrome Radiologically isolated syndrome Not active Active Highly active Without progression With progression Worsening Stable |
Clinical criteria for dissemination in time and space are met MAGNIMS criteria are met Annualized relapse rate: 2/year Other relevant aspects: Lymphocyte count 01/2017: 1.69/nl Anti-JCV antibody serological index 01/2016: negative 01/2017: negative Annualized relapse rate: 2/year Other relevant aspects: mild skin irritation reaction Hashimoto’s thyroiditis Patient is planning to have a child in the next 1 or 2 years. |
This patient is a 27-year-old woman suffering from a relapsing–remitting MS with a current EDSS score of 3. First symptoms occurred in 2010, and she was diagnosed with MS in May 2012 according to the revised McDonald criteria (
Besides the essential information extracted from the above presented medical history, the neurologist may feed further patient-related information into FAST, which is relevant to facilitate DMT decision as well as to monitor the further therapy. For example, any plans of the patient to have children in the near future may be documented so that therapies with presumed teratogenicity may be avoided or timely discontinued. Disease duration (relevant in patients with disease duration <10 years) can also be fed into FAST and further updated. Any relevant concomitant medical condition that might reduce the individual risk–benefit ratio from a particular DMT (such as Hashimoto’s thyroiditis and liver disease) can also be documented. Anti-JCV antibody serological index that increases the risk for developing a PML under escalation DMTs can be documented and monitored using FAST.
Table
Five-dimensional approach for surveillance and therapy does not replace the current MS classification, the EDSS, the neurologist’s medical report, or MS registries and databases. Strictly speaking, it does not offer new elements beyond the knowledge that neurologists already apply in their daily practice. It rather offers an opportunity for the treating specialist to improve the organization of clinical reports, while having all relevant information in one place, easily accessible for a quick overview, thus facilitating surveillance and therapeutic decision making. Well-designed registries and databases offer more detailed information on the disease course and are an essential prerequisite for scientific analyses. However, they are less practicable when it comes to the extraction and weighting of individual data in daily routine.
Introducing FAST in clinical practice offers four main advantages. First, it contributes decisively to patient safety by presenting essential therapy-related information in a structured way, which enables easier update of information. Consequently, the treating neurologist is always aware of the individual risks of his/her patients when considering a particular DMT. Thus, monitoring the current therapy is more easily ensured. A widespread use of FAST would simplify information transfer after switching to a new clinic or a new neurologist. Second, using FAST saves time. While extensive medical reports are not replaced by FAST, new patient-related information such as imaging findings, relapses, etc. can be easily fed in the respective dimensions of FAST. Thus, the most relevant patient-associated information is summarized in a condensed and consistent way, allowing the neurologist to access it without having to read the entire medical reports anew. Third, using FAST can be beneficial especially for didactic reasons: neurologists in training can more easily overview the complex information that has to be considered when recommending or monitoring a DMT. This applies also for specialists working in regions with low MS prevalence or in clinics treating only a low number of MS patients. Last but not least, FAST offers a simple and effective way of screening patients with regard to study inclusion criteria. All of the relevant information like phenotype, EDSS, activity, diagnostic criteria, former DMTs, disease duration, and other medical conditions are stored in one tool, where the information is not only presented in a structured and patient-related way but can also be easily updated.
YY, CF, MW, and JG developed and discussed the main idea of the manuscript. YY, CF, and JG wrote the manuscript.
YY and JG have no conflicts of interest. CF received speaking honoraria and honoraria for active participation in advisory boards from TEVA, Roche, and Genzyme. MW’s work has been supported by a research grant from TEVA.
The authors thank Christine Schuhmann for her support and assistance.