Clinical Review

Diagnosis and treatment of multiple sclerosis

BMJ 2006; 332 doi: 10.1136/bmj.332.7540.525 (Published 2 March 2006)
Cite this as: BMJ 2006;332:525

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  1. T J Murray, professor emeritus (jock.murray@dal.ca)1
  1. 1 Sir Charles Tupper Medical Building, Dalhousie University, 5849 University Avenue, Halifax, NS, Canada B3H 4H7
  • Accepted 31 January 2006

Introduction

Multiple sclerosis is the most common disabling neurological disease in young adults. Recent advances in understanding the underlying mechanisms and the development of new therapies have increased hope for doctors and their patients. New therapies are available and many other agents are undergoing clinical trials. New information does reveal some disturbing aspects of the disease however. Evidence from several sources suggests that the disease is present long before the first symptom. The disease is also more widespread and continuous than previously thought, with changes in grey as well as white matter and changes in normal appearing white matter. Multiple sclerosis has long been regarded as a demyelinating disease, but evidence now suggests widespread damage to axons that may be more closely correlated with progression of disability. Better understanding of the underlying mechanisms of the disease is allowing more focused development of new therapies.

Sources and selection criteria

This review is based on the conclusions of recent randomised clinical trials, the 15 Cochrane reviews of multiple sclerosis therapy, and guidelines of the American Academy of Neurology.

Diagnosis

Since the early 1980s the Poser criteria was used to classify multiple sclerosis. This relied on evidence of at least two relapses typical of multiple sclerosis and evidence of involvement of white matter in more than one site in the central nervous system, the concept of “lesions scattered in time and space.” A new system of classification, the McDonald criteria (see bmj.com), incorporates clinical and laboratory elements, allowing an earlier confirmation of the diagnosis and thus enabling earlier decisions about starting disease modifying therapies.1 2 Multiple sclerosis is a clinical diagnosis on the basis of two episodes involving two or more areas of the central nervous system over time, but the McDonald criteria incorporate magnetic resonance imaging to demonstrate multiple areas of involvement and also involvement over time …

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