Takeaways From the New Diagnostic Criteria for Multiple Sclerosis (Podcast)

When new revisions of the McDonald criteria were recently unveiled at ECTRIMS 2024 in Copenhagen, it marked the first update to these influential criteria for the diagnosis of multiple sclerosis (MS) since 2017.

“While the 2017 criteria represented a substantial advance from the preceding version, they have had shortcomings,” says Daniel Ontaneda, MD, PhD, a contributor to the newly revised criteria. “On average, it still takes about two years from the onset of MS symptoms until diagnosis, and misdiagnosis occurs in about 20% of people diagnosed with MS. Given the potential benefits from early use of highly effective treatments for MS, the imperative for timely and accurate diagnosis is greater than ever.”

In the latest episode of Cleveland Clinic’s Neuro Pathways podcast, Dr. Ontaneda, a neurologist with Cleveland Clinic’s Mellen Center for Multiple Sclerosis Treatment and Research, shares key changes and improvements in the new McDonald criteria, along with their potential implications for practice. He touches on the following topics, among others:

• The evolution of MS diagnosis, including progress and challenges with the 2017 McDonald criteria
• Integration of the optic nerve as a fifth topography in MS diagnosis
• Use of the central vein sign and paramagnetic rim lesions as imaging biomarkers
• The role of oligoclonal bands and kappa free light chain as diagnostic tools
• Circumstances in which MS can now be diagnosed in individuals with minimal or no symptoms
• Plans for dissemination of the revised criteria

Click the podcast player above to listen to the 33-minute episode now, or read on for a short edited excerpt. Check out more Neuro Pathways episodes at clevelandclinic.org/neuropodcast or wherever you get your podcasts.

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Excerpt from the podcast

Daniel Ontaneda, MD, PhD: One of the biggest changes is that the new diagnostic criteria say, for the first time, that under certain circumstances — that is, in the presence of specific biomarkers such as paramagnetic rim lesions, presence of the central vein, positive cerebrospinal fluid — you can make a diagnosis of MS in an asymptomatic individual. This is something we previously called radiologically isolated syndrome, and we would counsel patients that we think it is an early form of MS but we typically would not treat it unless they were accumulating new lesions over time.

In contrast, now we’re saying that, under certain conditions, you can diagnose MS in an asymptomatic individual and you could potentially start treatment…. So that will likely be a big change for neurologists to think about, as making a diagnosis in an asymptomatic individual is something that will take some getting used to. And this also raises the question of how to handle medications that are currently approved to treat MS — that is, whether and when they should be used in asymptomatic individuals who are diagnosed with MS.

So there’s going to be a bit of a learning curve. And our dogma of treating everybody who has MS as early as possible and with as potent medications as possible needs to be considered anew in the context of an asymptomatic patient. While prescribers may be more likely to take some risks with a high-efficacy treatment if a patient has already had at least one attack, selling a patient with no symptoms on a potent medication they have to take for many years might be a bit more difficult.