https://doi.org/10.1177/1352458518798147 https://doi.org/10.1177/1352458518798147 MULTIPLE SCLEROSIS MSJ JOURNAL journals.sagepub.com/home/msj 1 Multiple Sclerosis Journal 1–9 DOI: 10.1177/ 1352458518798147 © The Author(s), 2018. Article reuse guidelines: sagepub.com/journals- permissions Introduction At least twice yearly clinical visits and yearly magnetic resonance imaging (MRI) scans is the current best practice for predicting treatment response in patients with relapsing-remitting mul- tiple sclerosis (RRMS). With regular utilization of sensitive MRI techniques, subclinical new T2 or T1 gadolinium-enhancing (Gd+) lesions are now frequently encountered and are determining fac- tors for both disease activity and treatment effi- cacy. 1,2 Guidelines from Magnetic Resonance Imaging in multiple sclerosis (MAGNIMS) and Consortium of multiple sclerosis Centres (CMSC) support early on-treatment MRI assessments as a means to predict response to treatment, future relapses, and long-term disability. 3,4 Inevitably, clinicians are increasingly vigilant in monitoring for MRI subclinical activity and using this as an impetus to change disease-modifying therapies (DMTs) and strive for no evidence of disease activ- ity (NEDA). The NEDA-3 criteria include no clini- cal relapses, no sustained disability progression, and no Gd+ lesions and/or new or enlarging T2 lesions on MRI brain scans. 5 Silent lesions on MRI imaging – Shifting goal posts for treatment decisions in multiple sclerosis Myintzu Min, Tim Spelman, Alessandra Lugaresi, Cavit Boz, Daniele LA Spitaleri, Eugenio Pucci, Francois Grand’Maison, Franco Granella, Guillermo Izquierdo, Helmut Butzkueven, Jose Luis Sanchez-Menoyo, Michael Barnett, Marc Girard, Maria Trojano, Pierre Grammond, Pierre Duquette, Patrizia Sola, Raed Alroughani, Raymond Hupperts, Steve Vucic, Tomas Kalincik, Vincent Van pesch and Jeannette Lechner-Scott; on behalf of MSBase Investigators Abstract Background: The current best practice suggests yearly magnetic resonance imaging (MRI) to monitor treatment response in multiple sclerosis (MS) patients. Objective: To evaluate the current practice of clinicians changing MS treatment based on subclinical new MRI lesions alone. Methods: Using MSBase, an international MS patient registry with MRI data, we analysed the probabil- ity of treatment change among patients with clinically silent new MRI lesions. Results: A total of 8311 MRI brain scans of 4232 patients were identified. Around 26.9% (336/1247) MRIs with one new T2 lesion were followed by disease-modifying therapy (DMT) change, increasing to 50.2% (129/257) with six new T2 lesions. DMT change was twice as likely with new T1 contrast enhanc- ing compared to new T2 lesions odds ratio (OR): 2.43, 95% confidence interval (CI): 2.00–2.96 vs OR: 1.26 (95% CI: 1.22–1.29). DMT change with new MRI lesions occurred most frequently with ‘injectable’ DMTs. The probability of switching therapy was greater only after high-efficacy therapies became avail- able in 2007 (after, OR: 1.43, 95% CI: 1.28–1.59 vs before, OR: 0.98, 95% CI: 0.520–1.88). Conclusion: MS clinicians rely increasingly on MRI alone in their treatment decisions, utilizing low thresholds (1 new T2 lesion) for optimizing MS therapy. This signals a shift towards no evidence of dis- ease activity (NEDA)-3 since high-efficacy therapies became available. Keywords: Disease-modifying therapy, magnetic resonance imaging, subclinical lesions Date received: 15 April 2018; revised: 30 June 2018; accepted: 18 July 2018 Correspondence to: J Lechner-Scott Department of Neurology, John Hunter Hospital, Lookout Road, New Lambton Heights, Newcastle, NSW 2305, Australia. Jeannette.Lechner-Scott@ hnehealth.nsw.gov.au Myintzu Min Department of Neurology, John Hunter Hospital, Newcastle, NSW, Australia Tim Spelman Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden/ Burnet Institute for Medical Research and Public Health, Melbourne, VIC, Australia Alessandra Lugaresi Department of Biomedical and Neuromotor Sciences (DIBINEM), University of Bologna, Bologna, Italy/ IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy Cavit Boz KTU Medical Faculty Farabi Hospital, Trabzon, Turkey Daniele LA Spitaleri Azienda Ospedaliera di Rilievo Nazionale San Giuseppe Moscati Avellino, Avellino, Italy Eugenio Pucci UOC Neurologia, Azienda Sanitaria Unica Regionale Marche–AV3, Macerata, Italy Francois Grand’Maison Neuro Rive-Sud, Greenfield Park, QC, Canada Franco Granella Department of Medicine and Surgery, Unit of Neuroscience, University of Parma, Parma, Italy 798147MSJ 0 0 10.1177/1352458518798147Multiple Sclerosis JournalM Min, T Spelman research-article 2018 Original Research Paper