We thank the authors of the Letter entitled “Should we stop using post-contrast sequences in the follow-up MRI of patients with
multiple sclerosis?” for having appreciated and commented on our work “Impact of post-contrast MRI in the definition of active multiple sclerosis” [
[1]
]. The issue of gadolinium (Gd) administration in people with MS (PwMS) is still under
debate. Post-Gd MRI sequences certainly provide useful diagnostic and prognostic information,
predicting treatment response and long-term disability [
[2]
,
[3]
]: such aspects were clearly presented in the Discussion section of our study [
[1]
]. At the same time, potential risks linked to Gd deposition in the central nervous
system (CNS) need to be considered when evaluating its repeated use in PwMS, even
if the clinical correlates of brain Gd retention have not clearly demonstrated. Accordingly,
in 2017, the International Society of Magnetic Resonance in Medicine (ISMRM) urged
caution in the use of gadolinium-based contrast agents and suggested that, “per standard
practice”, their use should be avoided when not necessary [
[4]
]. In this context, a research priority in MS is to identify the clinical scenario
that justify the use of Gd in follow-up MRIs. It is worth noting that, in the absence
of new/enlarged lesions in T2/FLAIR sequences, Gd administration allows the detection
of a very low percentage of reactivated lesions (e.g. one study found only 1 Gd + pre-existing
lesion that appeared unchanged in size on T2/FLAIR sequences in 138 follow-up MRIs
[
[5]
], while another study found that the overall probability of missing Gd + lesions
in patients with stable T2 follow-up examinations was 1.7% [
[6]
]). The results reported in our study provide further data in support of the rationalization
of Gd administration, since MS phenotype classification in our “active” population
[
[7]
] did not change in about 99% of cases after excluding T1-Gd images [
[1]
]. According with previous data, therefore, we believe that Gd should not routinely
administered in the MRI follow-up of MS patient and that its use could be limited
to the situations in which the information provided by post-contrast sequences might
impact MS diagnosis and therapeutic decisions. This approach also emerges from the
most recent MAGNIMS-CMSC-NAIMS international guidelines that provided recommendations
for the judicious use of gadolinium-based contrast agents for specific clinical purposes
in MS diagnosis and monitoring [
[8]
]. In the near future, regulatory National Health Agencies might consider these emerging/growing
data in order to update the MRI-based access to disease modifying drugs (DMDs).Keywords
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References
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Article info
Publication history
Published online: September 14, 2022
Accepted:
September 11,
2022
Received:
September 6,
2022
Identification
Copyright
© 2022 Elsevier B.V. All rights reserved.