Skip to main content
Download PDF
  • Position statement
  • Open access
  • Published:

Treatment of relapsing multiple sclerosis in Hungary – consensus recommendation from the Hungarian neuroimmunology society

Orphanet Journal of Rare Diseases volume 18, Article number: 183 (2023) Cite this article

Abstract

Multiple sclerosis (MS) may impact quality of life, careers and family plans of the affected individuals. The current treatments with disease modifying therapies aim to prevent people with MS (pwMS) from disability accumulation and progression. Different countries have different reimbursement policies resulting in inequalities in patient care among geographical regions. Access to anti-CD20 therapies for relapsing MS is restricted in Hungary because therapy of individual cases only is reimbursed. In the light of the latest research and national guidelines, 17 Hungarian MS experts agreed on 8 recommendations regarding relapsing pwMS using the Delphi round method. Strong agreement (> 80%) was achieved in all except one recommendation after three rounds, which generated a fourth Delphi round. The experts agreed on treatment initiation, switch, follow-up and discontinuation, as well as on special issues such as pregnancy, lactation, elderly population, and vaccination. Well-defined national consensus protocols may facilitate dialogue between policymakers and healthcare professionals and thus contribute to better patient care in the long run.

Introduction

MS is a leading cause of disability among young adults. This chronic neurodegenerative and autoimmune disease affects patients in their productive and fertile years. MS may also have an impact on the quality of life, professional career and family planning. Cognitive and physical disability has a significant economic burden and in a worst-case scenario leads to social isolation. The prevalence of MS is rising worldwide. In Hungary, MS prevalence is estimated between 101.4-127.2/100,000 measured by two different methodological approaches [1, 2]. This is similar to the prevalence of the neighboring country Croatia (143.8/100,000) [3]. The worldwide incidence is also increasing, and the highest increase in both incidence and prevalence happened in the elderly populations, especially in women between the age of 50–60 years [4].

The current treatments with disease modifying therapies (DMTs) aim to prevent people with MS (pwMS) from disability accumulation and progression. The use of the current DMTs contributed to decreased prevalence of the late progressive course (secondary progression). The introduction of high-efficacy therapies (HET) early in the disease course may reduce, halt or even reverse disability progression [5, 6]. The difference between reimbursement policies in Denmark and Sweden led to differences in patient outcome measures favoring the start with HET over the escalation model, which starts with platform therapy and switches the treatment to higher efficacy drug when disease activity is shown [7]. Several other recent real-word studies worldwide observed similar advantages of treatment start with HET [8,9,10]. These data are shaping the treatment strategy of MS, moving from escalation to the early initiation with HET. Such novel strategies are reflected even in national treatment guidelines [11,12,13].

The proportion of pwMS using HET has increased in Hungary as well along with markedly increased annual cost of MS treatments (Fig. 1). Of note, the clinical benefits and reduced disease burden are expected to be seen only in the long run. The measurement of socioeconomic advantages is even more complex.

Fig. 1
figure 1

The number of medication prescription of pwMS on HET between 2016 and 2021 -based on the data from the National Health Insurance Fund [18]. The DMTs are shown in the order of their approval by the national authorities. Cladribine has been accepted since January 2020 without restriction. The reimbursement of anti-CD20 therapies are available with restriction, the only exception is ocrelizumab for primary progressive MS with unrestricted availability since January 2022. Data on DMTs n < 10, e.g. rituximab are not shown

Full size image

Different countries have different reimbursement policies leading to inequalities between patient care in different geographical regions [14]. In the MS Barometer 2020, Hungary ranked in the middle range with 51 out of 100 points report [15] with relatively satisfying access to reimbursed therapies in 2018. According to the country-specific report [16], improved patient care may be achieved with the establishment of a national registry, guidelines on pediatric MS care, better access of patients to rehabilitation programs and symptomatic treatment. The report also suggested involvement of health care providers in the national reimbursement decision policies. In Hungary, treatments for pwMS approved by the European Medicines Agency (EMA) are usually available without reimbursement restrictions only by a delay of 2–4 years. During these years of restricted access, MS neurologists have to apply to the National Health Insurance Fund for reimbursement in each case. This is a time consuming process (mean evaluation time is 60 days) associated with a high administration load and high rejection rate. In Hungary, ocrelizumab is approved only for primary progressive MS, and individual applications are necessary for reimbursement in cases of relapsing MS. Of note, anti-CD20 therapies rank among the most effective therapies, especially if administered timely [17]. Lack of easily accessible anti-CD20 treatments for relapsing MS in Hungary complicates start with HET, escalation or switch strategies, especially in JCV positive patients with highly active or breakthrough disease (Fig. 1).

In 2018, the ECTRIMS guideline [19] was translated into Hungarian. The Hungarian national MS guideline was prepared in 2013, and a revised version is under development. The National Health Insurance Fund in Hungary uses a financial guideline with terms first and second line therapy, although these concepts are out of date in relation to the novel treatment strategies. Beside insufficient human resources and infrastructure [20], MS centers have to deal with restricted access to MS treatments in Hungary, which affects the quality of MS care.

The aim of our study is to highlight the required changes in Hungary and provide consensus recommendations on the treatment of relapsing MS by experts on a national level using the Delphi method.

Methods

From November 2022 to February 2023, monthly online meetings of the Committee of the Hungarian Neuroimmunology Society addressed the preparation of a state-of-art national treatment recommendation using the Delphi method to achieve consensus [21]. Beside the Committee members of the Hungarian Neuroimmunology Society, MS experts from the largest national MS centers have also been involved in the rounds. The 17 consultant neurologists involved were covering the geographical distribution of Hungary and represented the staff of the largest MS centers in Hungary. The discussion about the recommendation was shaped by the 11 Steering Committee members of the Hungarian Neuroimmunology Society actually updating the Hungarian National MS Guidelines on monthly zoom meetings starting in November 2021 until November 2022, and the first Delphi round started in November 2022.

The participants could express their agreement on a 7-point scale (strongly agree, agree, somewhat agree, neither agree or disagree, somewhat disagree, disagree, strongly disagree). Consensus was achieved by agreements of > 80% on online distributed lists of open ended recommendations in 4 rounds.

Results

Recommendation 1

DMT should be offered to all patients with relapsing MS diagnosed based on the 2017 McDonald criteria [22]. Disease activity and prognostic factors should be considered in the choice of the disease modifying drug (Table 1). High-efficacy therapy (HET) should be offered to pwMS with high disease activity and poor prognostic factors (Table 2).

Table 1 Prognostic factors influencing MS disease outcome
Full size table
Table 2 DMTs in the treatment of MS
Full size table

Agreement achieved in Round 4 (88.24% agreed strongly, 5.88% agreed and 5.88% agreed somewhat).

Recommendation 2

Patients on DMTs should be seen at least every 6 months by an MS specialist in an MS center and followed at least 6-monthly by expanded disability status scale (EDSS), and at least yearly by single digit modality test, 9-hole peg test and 25-feet walking test. For specific follow up on treatments, see the summary of product characteristics.

Agreement achieved in Round 2 (100% strongly agreed).

Recommendation 3

Escalation of the therapy should be considered if the patient while on moderate efficacy therapy has a relapse and/or more than 2 new or enlarging T2 and/or Gd enhancing lesions on the follow-up annual MRI. Lateral switch is not recommended while on moderate efficacy therapy, unless the change of therapy is initiated due to side effects or intolerance or pregnancy planning.

After the 4th round 82.35% of the respondents have strongly agreed, and 17.65% agreed.

Recommendation 4

In case of signs of radiological and/or clinical disease activity while on HET, change of therapy to another HET should be considered. For wash out time see Table 3.

Table 3 Wash out times for different DMTs
Full size table

In Round 2 the respondents answered with the following answers: 82.35% strongly agreed, 5.88 agreed.

Recommendation 5

Regardless of age, de-escalation/discontinuation of treatment needs a cautious approach. In patients with progressive disease and EDSS ≥ 7, de-escalation/discontinuation can be considered. In non-progressive disease without clinical and MRI activity for years, de-escalation/discontinuation always needs individual assessment and is not routinely recommended. This should be based on the age, adverse events, potential risks of AEs, comorbidities and their treatment, radiological and clinical activity in the preceding 5 years, the ongoing DMT (caution particularly with natalizumab and fingolimod), and the effects/AEs of previous DMTs.

Agreement achieved in Round 2 (88.24% agreed strongly and 11.76% agreed).

Recommendation 6

MS does not affect fertility; it has no adverse effect on pregnancy or neonatal outcomes. Women with family plans are advised to postpone the pregnancy until their disease is stable. Hormonal contraception is not contraindicated in MS. In case of IVF, GnRH agonists should be avoided. Both obstetric and neurological follow-up is recommended before, during and after the pregnancy. The risk of MS relapse decreases during pregnancy but increases in the first few months after birth. In case of relapses during pregnancy, indication of the corticosteroid treatment (500-1000 mg methylprednisolone (or equivalent) daily for 3–5 days) should be decided on a case-by-case basis. MRI without gadolinium contrast agent is permitted if necessary. MS professionals should consider the safety of a treatment during pregnancy when prescribing DMT to women of childbearing age. Administration of interferon-beta, glatiramer acetate, and natalizumab can be considered during pregnancy. Dimethyl fumarate and anti-CD20 therapies can be continued until pregnancy. For more details regarding DMT use in pregnancy and breastfeeding, see Table 4. During breastfeeding, short corticosteroid pulse therapy is permitted if necessary and should be decided individually.

Table 4 DMT use and family planning
Full size table

The responses in Round 2 were strongly agree: 82.24%, agree: 5.88% and somewhat disagree 5.88%.

Recommendation 7

PwMS should be informed about optimal individualized immunization at diagnosis but latest before starting DMTs. Vaccines not containing live pathogens can be administered 3–5 days after short course of high dose corticosteroid treatment if the patient is in remission; live attenuated vaccines can be given 3 months after the steroid treatment. Ideally, vaccines not containing live pathogens should be administered at least 2–4 weeks before the start of the DMT (depending on the DMT), and the administration of the live attenuated vaccines (varicella, mumps, measles, rubella) should be completed 4–6 weeks before the start of the therapy. In case the initiation of DMT is urgent, one dosage from the varicella vaccine consisting of two dosages may be administered before the start of the therapy.

Agreement achieved in Round 2 (94.12% strongly agreed and 5.88% agreed).

Recommendation 8

The clinical phenotype of late-onset MS may be different from early-onset MS, and is characterized by higher percentage of progressive course, pyramidal and cerebellar symptoms, while sensory symptoms are less prevalent. However, patients with late-onset MS reach disability later and prognostic factors may be similar. Therefore, the type of disease course may be more important than the age of onset. In aging MS patients the clinical and radiological activity declines, while comorbidities become more common. Although treatment choice is not different in active late-onset MS or aging MS, comorbidities may be important (e.g. risk of malignancy, lymphopenia, hypogammaglobulinemia, hypertension, infection and PML).

Agreement achieved in Round 2 (94.12% strongly agreed and 5,88% agreed).

Conclusion

As our knowledge on MS pathomechanism is broadening, principles of treatment strategies change. Accordingly, treatment recommendations should be regularly updated. Several national guidelines are available with partial overlap. Definition of the disease activity and escalation strategy is somewhat different in the distinct guidelines (Table 5), probably reflecting adjustment to the different healthcare systems and additional factors at national level. Well-defined national consensus protocols may facilitate dialogue between policymakers and healthcare professionals and thus contribute to better patient care in the long run.

Table 5 Different approaches to therapy escalation
Full size table

It is important to note that the consensus recommendations are not intended to replace critical thinking or individualization of the choice of DMTs and patient care.

Data availability

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Abbreviations

CSF:

cerebrospinal fluids

DMT:

disease modifying therapy

ECTRIMS:

European Committee for Research and Treatment in Multiple Sclerosis

EDSS:

expanded disability status scale

EMA:

European Medicines Agency

GW:

gestational week

Ig:

immunoglobulin

i.m.:

intramuscular

i.v.:

intravenous

MS:

multiple sclerosis

pwMS:

people with MS

s.c.:

subcutaneous

References

  1. Iljicsov A, Milanovich D, Ajtay A, Oberfrank F, Bálint M, Dobi B, Bereczki D, Simó M. Incidence and prevalence of multiple sclerosis in Hungary based on record linkage of nationwide multiple healthcare administrative data. PLoS ONE. 2020;15:e0236432.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  2. Biernacki T, Sandi D, Fricska-Nagy Z, Kincses ZT, Füvesi J, Laczkó R, Kokas Z, Klivényi P, Vécsei L, Bencsik K. Epidemiology of multiple sclerosis in Central Europe, update from Hungary. Brain Behav. 2020;10:e01598.

    Article  PubMed  PubMed Central  Google Scholar 

  3. Benjak T, Štefančić V, Draušnik Ž, Cerovečki I, Roginić D, Habek M, et al. Prevalence of multiple sclerosis in Croatia: data from national and non-governmental organization registries. Croat Med J. 2018;59:65–70.

    Article  PubMed  PubMed Central  Google Scholar 

  4. Bentzen J, Flachs EM, Stenager E, Brønnum-Hansen H, Koch-Henriksen N. Prevalence of multiple sclerosis in Denmark 1950–2005. Mult Scler. 2010;16:520–5.

    Article  PubMed  Google Scholar 

  5. Kalincik T, Diouf I, Sharmin S, Malpas C, Spelman T, Horakova D, Havrdova EK, Trojano M, Izquierdo G, Lugaresi A, Prat A, Girard M, Duquette P, Grammond P, Jokubaitis V, van der Walt A, Grand’Maison F, Sola P, Ferraro D, Shaygannejad V, Alroughani R, Hupperts R, Terzi M, Boz C, Lechner-Scott J, Pucci E, Van Pesch V, Granella F, Bergamaschi R, Spitaleri D, Slee M, Vucic S, Ampapa R, McCombe P, Ramo-Tello C, Prevost J, Olascoaga J, Cristiano E, Barnett M, Saladino ML, Sanchez-Menoyo JL, Hodgkinson S, Rozsa C, Hughes S, Moore F, Shaw C, Butler E, Skibina O, Gray O, Kermode A, Csepany T, Singhal B, Shuey N, Piroska I, Taylor B, Simo M, Sirbu CA, Sas A, Butzkueven H. MSBase Study Group. Effect of Disease- modifying therapy on disability in relapsing-remitting multiple sclerosis over 15 years. Neurology. 2021;96:e783–e97.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  6. Brown JWL, Coles A, Horakova D, Havrdova E, Izquierdo G, Prat A, Girard M, Duquette P, Trojano M, Lugaresi A, Bergamaschi R, Grammond P, Alroughani R, Hupperts R, McCombe P, Van Pesch V, Sola P, Ferraro D, Grand’Maison F, Terzi M, Lechner-Scott J, Flechter S, Slee M, Shaygannejad V, Pucci E, Granella F, Jokubaitis V, Willis M, Rice C, Scolding N, Wilkins A, Pearson OR, Ziemssen T, Hutchinson M, Harding K, Jones J, McGuigan C, Butzkueven H, Kalincik T, Robertson N. MSBase Study Group. Association of initial disease-modifying therapy with later Conversion to secondary progressive multiple sclerosis. JAMA. 2019;321:175–87.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  7. Spelman T, Magyari M, Piehl F, Svenningsson A, Rasmussen PV, Kant M, Sellebjerg F, Joensen H, Hillert J, Lycke J. Treatment escalation vs Immediate initiation of highly effective treatment for patients with relapsing-remitting multiple sclerosis: data from 2 different national strategies. JAMA Neurol. 2021;78:1197–204.

    Article  PubMed  Google Scholar 

  8. Buron MD, Chalmer TA, Sellebjerg F, Barzinji I, Christensen JR, Christensen MK, Hansen V, Illes Z, Jensen HB, Kant M, Papp V, Petersen T, Rasmussen PV, Schäfer J, Theódórsdóttir Á, Weglewski A, Sorensen PS, Magyari M. Initial high-efficacy disease-modifying therapy in multiple sclerosis: a nationwide cohortstudy. Neurology. 2020;95:e1041–51.

    Article  CAS  PubMed  Google Scholar 

  9. Filippi M, Danesi R, Derfuss T, Duddy M, Gallo P, Gold R, Havrdová EK, Kornek B, Saccà F, Tintoré M, Weber J, Trojano M. Early and unrestricted access to high-efficacy disease-modifying therapies: a consensus to optimize benefits for people living with multiple sclerosis. J Neurol. 2022;269:1670–7.

    Article  PubMed  Google Scholar 

  10. Montalban X, Matthews PM, Simpson A, Petrie JL, Sammon C, Ramagopalan S, Disanto G, Kuhle J. Real-world evaluation of ocrelizumab in multiple sclerosis: a systematic review. Ann Clin Transl Neurol. 2023;2. https://doi.org/10.1002/acn3.51732. Epub ahead of print. PMID: 36728340.

  11. Freedman MS, Devonshire V, Duquette P, Giacomini PS, Giuliani F, Levin MC, Montalban X, Morrow SA, Oh J, Rotstein D, Yeh EA, Canadian MS, Working Group. Treatment optimization in multiple sclerosis: canadian MS Working Group Recommendations. Can J Neurol Sci. 2020;47:437–55.

    Article  PubMed  Google Scholar 

  12. Wiendl H, Gold R, Berger T, Derfuss T, Linker R, Mäurer M, Aktas O, Baum K, Berghoff M, Bittner S, Chan A, Czaplinski A, Deisenhammer F, Di Pauli F, Du Pasquier R, Enzinger C, Fertl E, Gass A, Gehring K, Gobbi C, Goebels N, Guger M, Haghikia A, Hartung HP, Heidenreich F, Hoffmann O, Kallmann B, Kleinschnitz C, Klotz L, Leussink VI, Leutmezer F, Limmroth V, Lünemann JD, Lutterotti A, Meuth SG, Meyding-Lamadé U, Platten M, Rieckmann P, Schmidt S, Tumani H, Weber F, Weber MS, Zettl UK, Ziemssen T, Zipp F. Multiple sclerosis therapy Consensus Group’ (MSTCG). Multiple sclerosis therapy Consensus Group (MSTCG): position statement on disease-modifying therapies for multiple sclerosis (white paper). Ther Adv Neurol Disord. 2021;14:17562864211039648.

    Article  PubMed  PubMed Central  Google Scholar 

  13. Habek M, Adamec I, Barun B, Bašić Kes V, Bogoje Raspopović A, Duka Glavor K, et al. Treatment of relapsing multiple sclerosis - recommendations of the croatian neurological society. Croat Med J. 2022;63:379–88.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  14. Coetzee T, Thompson AJ, Atlas of MS. 2020: Informing global policy change. Mult Scler J 2020;26:1807–8. https://doi.org/10.1177/1352458520968811.

  15. https://www.emsp.org/wp-content/uploads/2021/03/MS-Barometer2020-Final-Full-Report-Web.pdf, accessed 3rd November 2022.

  16. https://www.healthpolicypartnership.com/app/uploads/MS-Barometer-factsheet-Hungary.pdf, accessed 3rd November 2022.

  17. Samjoo IA, Worthington E, Drudge C, Zhao M, Cameron C, Häring DA, Stoneman D, Klotz L, Adlard N. Comparison of ofatumumab and other disease-modifying therapies for relapsing multiple sclerosis: a network meta-analysis. J Comp Eff Res. 2020;9:1255–74.

    Article  PubMed  Google Scholar 

  18. http://www.neak.gov.hu/felso_menu/szakmai_oldalak/publikus_forgalmi_adatok/gyogyszer_forgalmi_adatok accessed 3rd November 2022.

  19. Montalban X, Gold R, Thompson AJ, Otero-Romero S, Amato MP, Chandraratna D, et al. ECTRIMS/EAN Guideline on the pharmacological treatment of people with multiple sclerosis. Mult Scler J. 2018;24:96–120.

    Article  Google Scholar 

  20. Kokas Z, Sandi D, Fricska-Nagy Z, Füvesi J, Biernacki T, Köves Á, Fazekas F, Birkás AJ, Katona G, Kovács K, Milanovich D, Dobos E, Kapás I, Jakab G, Csépány T, Bense E, Mátyás K, Rum G, Szolnoki Z, Deme I, Jobbágy Z, Kriston D, Gerócs Z, Diószeghy P, Bors L, Varga A, Kerényi L, Molnár G, Kristóf P, Nagy Z, Sátori M, Imre P, Péntek S, Klivényi P, Kincses ZT, Vécsei L, Bencsik K. Do hungarian multiple sclerosis care units fulfil international criteria? PLoS ONE. 2022;17:e0264328.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  21. Hsu CC, Sandford B. The Delphi technique: making sense of Consensus. Practical Assess Res Evaluation. 2007;12:1–8.

    Google Scholar 

  22. Thompson AJ, Banwell BL, Barkhof F, Carroll WM, Coetzee T, Comi G, Correale J, Fazekas F, Filippi M, Freedman MS, Fujihara K, Galetta SL, Hartung HP, Kappos L, Lublin FD, Marrie RA, Miller AE, Miller DH, Montalban X, Mowry EM, Sorensen PS, Tintoré M, Traboulsee AL, Trojano M, Uitdehaag BMJ, Vukusic S, Waubant E, Weinshenker BG, Reingold SC, Cohen JA. Diagnosis of multiple sclerosis: 2017 revisions of the McDonald criteria. Lancet Neurol. 2018;17:162–73.

    Article  PubMed  Google Scholar 

  23. Rotstein D, Montalban X. Reaching an evidence-based prognosis for personalized treatment of multiple sclerosis. Nat Rev Neurol. 2019;15:287–300.

    Article  PubMed  Google Scholar 

  24. Bigaut K, Cohen M, Durand-Dubief F, Maillart E, Planque E, Zephir H, Lebrun-Frenay C, de Seze J. French Group for Recommendations in multiple sclerosis (France4MS) and the Société Française de la Sclérose En plaques (SFSEP). How to switch disease-modifying treatments in multiple sclerosis: guidelines from the french multiple sclerosis society (SFSEP). Mult Scler Relat Disord. 2021;53:103076.

    Article  CAS  PubMed  Google Scholar 

  25. Krysko KM, Dobson R, Alroughani R, Amato MP, Bove R, Ciplea AI, Fragoso Y, Houtchens M, Jokubaitis VG, Magyari M, Abdelnasser A, Padma V, Thiel S, Tintore M, Vukusic S, Hellwig K. Family planning considerations in people with multiple sclerosis. Lancet Neurol. 2023;22:350–66.

    Article  PubMed  Google Scholar 

  26. Río J, Comabella M, Montalban X. Predicting responders to therapies for multiple sclerosis. Nat Rev Neurol., Castilló J, Rovira A, Tintoré M, Sastre-Garriga J, Horga A, Nos C, Comabella M, Aymerich X, Montalbán X. Measures in the first year of therapy predict the response to interferon beta in MS. Mult Scler. 2009;15:848 – 53.

  27. Sormani MP, Gasperini C, Romeo M, Rio J, Calabrese M, Cocco E, Enzingher C, Fazekas F, Filippi M, Gallo A, Kappos L, Marrosu MG, Martinelli V, Prosperini L, Rocca MA, Rovira A, Sprenger T, Stromillo ML, Tedeschi G, Tintorè M, Tortorella C, Trojano M, Montalban X, Pozzilli C, Comi G, De Stefano N. MAGNIMS study group. Assessing response to interferon-β in a multicenter dataset of patients with MS. Neurology. 2016;87:134–40.

    Article  CAS  PubMed  Google Scholar 

  28. Rotstein DL, Healy BC, Malik MT, Chitnis T, Weiner HL. Evaluation of no evidence of disease activity in a 7-year longitudinal multiple sclerosis cohort. JAMA Neurol. 2015;72:152–8.

    Article  PubMed  Google Scholar 

  29. Rae-Grant A, Day GS, Marrie RA, Rabinstein A, Cree BAC, Gronseth GS, Haboubi M, Halper J, Hosey JP, Jones DE, Lisak R, Pelletier D, Potrebic S, Sitcov C, Sommers R, Stachowiak J, Getchius TSD, Merillat SA, Pringsheim T. Comprehensive systematic review summary: Disease-modifying therapies for adults with multiple sclerosis: Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology. Neurology. 2018;90:789–800. Erratum in: Neurology. 2019 Oct 22;93(17):769.

Download references

Acknowledgements

Not applicable.

Funding

University of Szeged Open Access Fund Grant number 6071.

Open access funding provided by University of Szeged.

Author information

Authors and Affiliations

  1. Department of Neurology, Albert Szent-Györgyi Health Centre, University of Szeged, Semmelweis u.6, Szeged, 6725, Hungary

    Cecilia Rajda

  2. Department of Neurology, Jahn Ferenc Teaching Hospital, Köves u. 1, Budapest, 1204, Hungary

    Csilla Rózsa & Gábor Lovas

  3. Department of Neurology, Szent Borbála Hospital, Dózsa György u. 77, Tatabánya, 2800, Hungary

    Andrea Mike

  4. Department of Neurology, Faculty of Medicine, Semmelweis University, Balassa u. 6, Budapest, 1083, Hungary

    Zsolt Mezei & Magdolna Simó

  5. Department of Neurology, Uzsoki Hospital, Uzsoki u. 29-41, Budapest, 1145, Hungary

    Gábor Jakab

  6. Department of Neurology, Medical School, University of Pécs, Rét u. 2, Pécs, 7623, Hungary

    Péter Ács & Anita Trauninger

  7. Petz Aladár Department of Neurology, County Teaching Hospital, Vasvári Pál u. 2-4, Győr, 9024, Hungary

    Gábor Rum

  8. Department of Neurology, Bács-Kiskun County Teaching Hospital, Kecskemét, Nyíri u. 38, Kecskemét, 6000, Hungary

    Zita Jobbágy

  9. Department of Neurology, Flór Ferenc Hospital, Semmelweis tér 1, Kistarcsa, 2143, Hungary

    Zita Bíró

  10. Department of Neurology, Csolnoky Ferenc Hospital, Kórház u. 1, Veszprém, 8200, Hungary

    Piroska Imre

  11. Department of Neurology, Markhot Ferenc Teaching Hospital, Knézich K. u. 1, Eger, 3300, Hungary

    Klotild Mátyás

  12. Department of Neurology, Kaposi Mór Teaching Hospital, Tallián Gyula u 20-32, Kaposvár, 7400, Hungary

    István Deme

  13. Department of Neurology, Odense University Hospital, Institute of Clinical Research, University of Southern Denmark, Winslows vej 4, Odense, 5000, Denmark

    Zsolt Illés

  14. Department of Neurology, Faculty of Medicine, University of Debrecen, Móricz Zs. Krt. 22, Debrecen, 4032, Hungary

    Tunde Csepany

Authors
  1. Cecilia Rajda
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Csilla Rózsa
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Andrea Mike
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Gábor Lovas
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Zsolt Mezei
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Gábor Jakab
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Péter Ács
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Gábor Rum
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Magdolna Simó
    View author publications

    You can also search for this author in PubMed Google Scholar

  10. Zita Jobbágy
    View author publications

    You can also search for this author in PubMed Google Scholar

  11. Zita Bíró
    View author publications

    You can also search for this author in PubMed Google Scholar

  12. Anita Trauninger
    View author publications

    You can also search for this author in PubMed Google Scholar

  13. Piroska Imre
    View author publications

    You can also search for this author in PubMed Google Scholar

  14. Klotild Mátyás
    View author publications

    You can also search for this author in PubMed Google Scholar

  15. István Deme
    View author publications

    You can also search for this author in PubMed Google Scholar

  16. Zsolt Illés
    View author publications

    You can also search for this author in PubMed Google Scholar

  17. Tunde Csepany
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

Study concept and design: ZI, CsR, GL, TC, ZM, AM and CR. CR,CsR, AM, GL, ZM, GJ, PÁ, GR, MS, ZJ, ZB, AT, IP, KM, ID, ZI and TC took part in the Delphi survey. Analysis and interpretation of data: CR, ZI, CsR, AM, GL, TC, GJ. CR drafted the manuscript, which was revised by TC and ZI. CR, CsR, AM, GL, ZM, GJ, PÁ, GR, MS, ZJ, ZB, AT, IP, KM, ID, ZI and TC commented on and approved the final form. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Cecilia Rajda.

Ethics declarations

Ethics approval and consent to participate

Not applicable.

Competing interests

CR participated as clinical investigator and/or received consultation and/or speaker fees and/or conference travel grants from: Biogen, Merck, Novartis, Sanofi Genzyme, Roche, Teva. IZ has served on scientific advisory boards, received support for congress participation, speaker honoraria, or for being member of clinical endpoint committees in clinical trials, and received research support for his laboratory from Biogen, Merck, Roche, Sanofi Genzyme, Novartis, Alexion, and Bristol Myers Squibb. CsR received speaker fees, conference honoraria from Biogen, Novartis, Merck, Roche, Sanofi.

AM participated as clinical investigator and/or received consultation and/or speaker fees and/or conference travel grants from Biogen, Merck, Novartis, Sanofi Genzyme, Roche, Teva. GL received speaker fees and honoraria form Biogen, Novartis, Merck, Roche, Sanofi. ZM received speaker fees and conference/travel grants from: Biogen, Merck, Novartis, Roche and Sanofi Genzyme. ÁP received received investigator and speaker fees from: Sanofi Genzyme, Roche. GJ, GR, AT, KM and ID reported no conflict of interest. MS participated as clinical investigator and received consultation / speaker fees and conference travel grants from: Biogen, Merck, Novartis, Sanofi Genzyme, Roche, Teva. ZJ received consultation fees, speaker fees and conference travel grants from: Biogen, Merck, Novartis, Sanofi Genzyme, Roche. ZB received congress support from Biogen, Merck, Novartis, Sanofi-Genzyme and Roche. IP participated as clinical investigator, and received consultation, and speaker fees, and conference travel grants from: Biogen, Merck, Novartis, Sanofi Genzyme. TC has received personal honoraria for speaking, advisory boards and travel expenses from Biogen, Novartis, Roche, Sanofi-Genzyme, Teva.

Consent for publication

Not applicable.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary Material 1

Supplementary Material 2

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Rajda, C., Rózsa, C., Mike, A. et al. Treatment of relapsing multiple sclerosis in Hungary – consensus recommendation from the Hungarian neuroimmunology society. Orphanet J Rare Dis 18, 183 (2023). https://doi.org/10.1186/s13023-023-02789-0

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1186/s13023-023-02789-0

Keywords

Orphanet Journal of Rare Diseases

ISSN: 1750-1172