MRI Markers Drive Expert Consensus on First-Line High-Efficacy MS Therapy

Imaging markers of high disease activity appeared to be the main driver of expert consensus to recommend monoclonal high-efficacy therapy (HET) for treatment-naive patients with relapsing-remitting multiple sclerosis (RRMS). The finding comes from a Delphi study conducted in France and published in the Journal of Neurology.

The study defined monoclonal HET as anti-CD20 and anti-α4-integrin antibodies. The authors noted a lack of consensus on which treatment-naive patients should receive HET as first-line therapy. They added that 2 large randomized trials of early HET initiation have yet to report results.

A panel of 31 neurologists rated 8 fictional clinical cases, plus variations in which a single patient characteristic was changed at a time, for a total of 108 statements. Ratings used a 5-point scale. Consensus required at least 80% of ratings at either the agreeing (4-5) or disagreeing (1-2) end of the scale, with a matching median score. All 31 experts responded to both rounds; the second round followed an online workshop. Consensus was reached for 89 of 108 statements (82.4%).

The factors that systematically led to consensus in favor of monoclonal HET were all imaging-based: a high brain lesion load (>20 lesions), 2 or more spinal cord lesions, 3 or more gadolinium-enhancing lesions, and 3 or more infratentorial lesions. Several other factors often, but not always, led to consensus: a moderate brain lesion load, an initial attack with clinically concerning symptoms, a single spinal cord lesion, 1 or 2 infratentorial lesions, a previous attack in the past 12 months, and cognitive impairment. Demographic and clinical history characteristics did not appear to lead experts to advise HET, although few cases involved non-Caucasian patients or comorbidities.

The authors cautioned that the cases were hypothetical and not representative of everyday practice. Changing one parameter at a time may not capture interactions between factors, and the scenarios did not explicitly address treatment safety. The authors stated that their proposed framework should not be used as a clinical guideline.

Source: Bourre B, Guerrier O, Ayrignac X, et al. DELPHI expert consensus-derived factors influencing the early use of monoclonal high-efficacy therapies in treatment-naïve patients with relapsing-remitting multiple sclerosis. J Neurol. 2026;273(11):679. doi:10.1007/s00415-026-14167-4