Iraqi experts consensus on the management of relapsing remitting multiple sclerosis in adults

Abstract

Objective

In Iraq, a lack of evidence-based management protocols for diagnosing, treating, and managing multiple sclerosis (MS) poses risks of suboptimal outcomes and clinical practice variability and potential harm to the patients. This study aimed to develop consensus recommendations regarding the diagnosis and management of MS in Iraq, specifically focusing on treatment-naïve patients, suboptimal responders, and women of childbearing age during preconception, pregnancy planning, and lactation.

Methods

A survey was conducted to collect feedback from a panel of ten key opinion leaders (KOLs), who evaluated and discussed the statements to determine agreement levels. The mini-Delphi method was employed to establish a consensus on the management recommendations, and a meeting was held to analyze the responses and ensure that the recommendations were based on current evidence and followed a consensus-driven approach.

Results

The Revised McDonald Criteria is recommended for MS diagnosis, which includes evidence of dissemination of disease characteristics in space and time. Disease activity and progression can be monitored using relapses, MRI activity, and short-term disability progression. Experts suggest initiating treatment at diagnosis using higher efficacy medications, such as cladribine, ocrelizumab, natalizumab, or rituximab, for patients with high disease activity after careful risk stratification. Injectable interferon preparations have a tolerable risk profile but have drawbacks, such as the route and frequency of administration. Overall, disease-modifying therapies (DMTs) have shown efficacy in reducing relapse rates and short-term disability.

Conclusion

This article presents expert panel recommendations for managing MS in Iraq, taking into account international guidelines, medication updates, and local resources. However, practical questions remain regarding the real-world use of disease-modifying therapies (DMTs). Personalizing treatment based on disease severity, prognosis, and individual risk factors while adhering to guidelines is crucial. A collaborative approach between healthcare providers and patients, considering individual preferences, is vital for achieving treatment goals.

Keywords:

• Disease-modifying therapies
• Iraq
• multiple sclerosis
• pregnancy
• pharmacological management
• treatment algorithm
• women

Transparency

Declaration of funding

This study was sponsored by Merck Serono Middle East FZ-Ltd., Dubai, UAE, an affiliate of Merck KGaA, Darmstadt, Germany (CrossRef Funder ID: 10.13039/100009945).

Declaration of financial/other relationships

The authors declare that they have no potential conflicts of interest to disclose, except for Dr. Murad Al-Naqshbandi, who is employed by Merck. Merck Serono Middle East FZ-Ltd. was only involved in funding the logistical arrangement for the meeting. Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Author contributions

All authors have made significant contributions to the conception, design, acquisition, analysis, and interpretation of data, and have been actively involved in drafting, revising, and approving the final version of this review article. Individual contributions are enlisted in the table below. Hayder K. Hassoun: drafting, revising, approving; Anmar Oday Hatem, Akram Al-Mahdawi, Sarwer Jamal Al-Bajalan, Ali Kadim Karim, Sarmad Abdulrasool Al-Mashta, Saif Mohammed Tawfeeq, Majeed Salih Hamad, Nawfal M. Sheaheed, and Samer Mohammed Ridha: drafting, approving; Murad Al-Naqshbandih: funding, conception, design; Hasan Aziz Al-Hamadani: conception, drafting, approving.

Acknowledgements

Editing support was provided by MEDCON and was funded by Merck Serono Middle East FZ-Ltd., Dubai, UAE, an affiliate of Merck KGaA, Darmstadt, Germany (CrossRef Funder ID: 10.13039/100009945).