Rewriting the prognosis of multiple sclerosis in Brazil: a 25-year perspective on evolving diagnostic criteria

Dear Editor,

In the issue 83.6 of Arquivos de Neuro-Psiquiatria, Menezes et al.[1] investigate whether the progressive adoption of more sensitive diagnostic criteria—from Poser through successive McDonald revisions—may be associated with less disability accumulation in patients with relapsing-remitting multiple sclerosis. To investigate this, the authors conducted a 25-year retrospective cohort study of 491 patients diagnosed between 1994 and 2019 in São Paulo, Brazil. This question is important because multiple sclerosis is the most common relapsing demyelinating disease of the central nervous system,[2] and its prognosis may have changed over the past 25 years.

A key finding of Menezes et al.¹ was that patients diagnosed in Epoch 3 (2011–2019)—McDonald 2010 and 2017's criteria—had a 63% lower risk of reaching 6.0 in the Expanded Disability Status Scale (EDSS) than those in Epoch 1 (1994–2001)—Posner's criteria. One explanation is that the newer diagnostic criteria reduced the median time to first disease-modifying therapy from 3 to 2 years and dramatically increased the proportion of patients treated before their second relapse (from 2.7–24.4%). By enabling diagnosis at the very first demyelinating event—such as optic neuritis, for which multiple sclerosis is a leading cause[3]—these more sensitive criteria ensure patients start their treatment sooner, further minimizing early disability accrual. A second contributing factor may be the introduction of high-efficacy therapies. A meta-analysis of 3,467 participants showed that early use of high-efficacy agents was associated with a 30% reduction in the risk of EDSS worsening at 5 years compared with escalating strategy.[4] [5] Likewise, the Brazilian Multiple Sclerosis Cohort (BRANDO) found that regions with higher average EDSS scores had lower rates of high-efficacy prescriptions—such as natalizumab—underscoring the impact of access to high-efficacy treatments.[6]

While more sensitive diagnostic criteria can raise concerns about misdiagnosis and overtreatment, real-world data from MS referral centers show that misdiagnosis with the 2017 McDonald criteria remains low.[7] Furthermore, these centers follow standardized care protocols—endorsed by the Brazilian Academy of Neurology and the Brazilian Committee for Treatment and Research in Multiple Sclerosis (BCTRIMS)—to proactively monitor and minimize treatment-related adverse events.[8] [9]

Another notable finding of Menezes et al.'s¹ study was a 53% lower hazard of conversion to SPMS in the most recent epoch compared with the Poser era. This is especially significant given the limited efficacy of both on-label and off-label disease-modifying therapies in preventing disability accrual in progressive multiple sclerosis.[10] Ultimately, the dramatic decline in disability progression and Secondary Progressive Multiple Sclerosis (SPMS) conversion over time likely reflects three game-changing advances in Brazil: the adoption of more sensitive diagnostic criteria enabling earlier recognition, the slashing of delays to treatment initiation, and the vastly expanded access to high-efficacy therapies. Together, these shifts have fundamentally reshaped the multiple sclerosis prognosis—demonstrating that when diagnosis is early and potent disease-modifying therapies (DMTs) are within reach, the trajectory of this disease can indeed be rewritten.

Authors' Contributions

Conceptualization: DC, GDS; Project administration: DC; Supervision: DC; Writing - original draft: GDS; Writing - review & editing: DC.

Editor-in-Chief: Hélio A. G. Teive (0000-0003-2305-1073).

Publikationsverlauf

Eingereicht: 02. Juni 2025

Angenommen: 13. Juni 2025

Artikel online veröffentlicht:
27. Oktober 2025

• References

• 1 Menezes FTL, Alencar JMD, Lopes AB, Amorim LdS, Portugal RP, Albuquerque FT. et al. The impact of changing diagnostic criteria on disability in a Brazilian multiple sclerosis cohort. Arq Neuropsiquiatr 2025; 83 (06) 1-9
• 2 Silva GD, Apóstolos-Pereira SL, Callegaro D. Estimated prevalence of AQP4 positive neuromyelitis optica spectrum disorder and MOG antibody associated disease in São Paulo, Brazil. Mult Scler Relat Disord 2023; 70: 104488
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• 9 Becker J, Ferreira LC, Damasceno A, Bichuetti DB, Christo PP, Callegaro D. et al. Recommendations by the Scientific Department of Neuroimmunology of the Brazilian Academy of Neurology (DCNI/ABN) and the Brazilian Committee for Treatment and Research in Multiple Sclerosis and Neuroimmunological Diseases (BCTRIMS) on vaccination in general and specifically against SARS-CoV-2 for patients with demyelinating diseases of the central nervous system. Arq Neuropsiquiatr 2021; 79 (11) 1049-1061
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