Multiple sclerosis: disease-modifying therapy and GP shared care

What multiple sclerosis is

Multiple sclerosis (MS) is a chronic, immune-mediated disease in which the body’s own immune system attacks the protective myelin sheath around the nerves of the brain and spinal cord. Scarring — “sclerosis” — interferes with the electrical signals nerves use to communicate, producing the range of neurological symptoms that define the condition: visual disturbance, limb weakness, numbness and tingling, coordination problems, fatigue, bladder dysfunction, and cognitive slowing, among others.

MS is the most common cause of non-traumatic neurological disability in young Australian adults. MS Australia estimates around 33,000 Australians live with MS — the majority diagnosed between 20 and 40 years of age, precisely when education, career, and family life are at their most demanding. Women are affected approximately three times more often than men. The latitude gradient is striking: Tasmania (~210 per 100,000) has roughly three times the prevalence of Queensland (~76 per 100,000), a pattern driven by vitamin D, sunlight, and possibly genetic factors.

The last decade has been genuinely transformative for MS management. High-efficacy disease-modifying therapies (DMTs) now give neurologists the ability to dramatically reduce attack frequency, new MRI lesion formation, and — if started early enough — long-term disability accumulation. Australian PBS funding through the Section 100 Highly Specialised Drugs program places most of these medicines within reach of every Australian through their neurologist’s Authority prescription. This article explains MS sub-types, how DMTs work and which are PBS-listed, the evidence behind early high-efficacy treatment, and — critically — the ongoing role a general practitioner plays in the shared-care model every person with MS depends on.

A. Core clinical — the AU general-practice framework

Understanding MS sub-types

The sub-type shapes which DMT your neurologist can access on the PBS, and how urgently treatment should begin.

Sub-type	Pattern	Frequency
RRMS — relapsing-remitting	Discrete attacks (relapses) with full or partial recovery; stable between attacks	~85% of new diagnoses
SPMS — secondary progressive	Former RRMS evolving to steady disability accumulation, with or without continuing relapses	~50% of RRMS over 15–20 years (rate falling on high-efficacy DMT)
PPMS — primary progressive	Gradual deterioration from onset; no clear discrete relapses	~10–15%; older onset, more equal sex ratio
CIS — clinically isolated syndrome	First demyelinating event (optic neuritis, transverse myelitis, brainstem) not yet meeting full MS criteria	High conversion to RRMS if MRI lesions present

Diagnosis is made by a neurologist using the 2017 McDonald criteria — dissemination of demyelinating lesions in space and time on brain and spinal cord MRI, with or without cerebrospinal fluid oligoclonal bands. The eTG Neurology module and ANZAN 2024 both guide Australian practice.

How DMTs work

DMTs do not repair existing nerve damage or reverse disability that has already accumulated. They reduce ongoing CNS inflammation, interrupt the immune attack on myelin, lower the relapse rate, diminish new MRI lesion formation, and — in high-efficacy classes — slow the accumulation of disability over years. The composite treatment target in active RRMS is called NEDA: no evidence of disease activity (no clinical relapses, no new or enlarging MRI T2 lesions, no confirmed disability progression). NICE NG220 recognises NEDA as the contemporary benchmark in active RRMS.

DMTs divide broadly into:

• Moderate-efficacy (platform) therapies: interferons (Avonex, Rebif, Betaferon, Plegridy), glatiramer acetate (Copaxone), teriflunomide (Aubagio), dimethyl/diroximel fumarate (Tecfidera). Oral or injectable, generally well-tolerated, appropriate for lower-activity disease or where pregnancy safety is the priority.
• High-efficacy therapies: anti-CD20 monoclonal antibodies (ocrelizumab/Ocrevus, ofatumumab/Kesimpta), natalizumab (Tysabri), S1P receptor modulators (fingolimod/Gilenya, ozanimod, ponesimod), cladribine (Mavenclad). More potent, requiring more intensive monitoring.
• AHSCT (autologous haematopoietic stem cell transplant): for highly active RRMS failing high-efficacy DMT — available at accredited Australian centres (St Vincent’s Sydney, Austin Melbourne, Royal Adelaide) per the MIST trial evidence.

Clinical assessment in general practice

Relapse history: a true relapse is new or worsening neurological symptoms lasting ≥24 hours, after a stable period of ≥30 days, without fever or infection. Document onset, duration, deficit, and degree of recovery. Distinguish a relapse from a pseudo-relapse — temporary worsening of pre-existing symptoms triggered by a urinary tract infection, viral illness, heat, or sleep deprivation, without new MRI activity.

Symptom inventory: fatigue (the most prevalent and disabling symptom, present in ~80% of patients), bladder and bowel dysfunction, cognitive slowing, mood, spasticity and gait, pain, and visual symptoms. The AMH and eTG Neurology provide full symptom management tables.

Mood screen: PHQ-9 at every review — approximately 50% of people with MS develop major depression over their lifetime, and suicide risk is elevated roughly twofold compared with the general population. An active mental health care plan is appropriate for almost all patients.

Bladder review: urinary urgency, frequency, incontinence, and recurrent UTIs should be reviewed at every GP visit. A missed or under-treated UTI is the single most common trigger of a pseudo-relapse in MS, and recurrent UTIs in patients with neurogenic bladder accelerate functional decline.

Pregnancy planning: multiple DMTs are teratogenic or require wash-out before conception. A planned discussion well before pregnancy is intended is essential — bring in the neurologist early.

Vaccination history: pre-DMT live vaccine completion is a narrow, time-sensitive clinical window that the GP is uniquely placed to manage.

GP examination for suspected relapse

A GP assessment of possible relapse covers: visual acuity and colour vision; eye movements (internuclear ophthalmoplegia — impaired adduction with contralateral nystagmus); limb tone, power, and reflexes; plantar responses; coordination (finger–nose test, gait, Romberg); and a sensory screen including vibration and pin-prick. Temperature and urine MC&S exclude pseudo-relapse from infection. For any suspected new relapse with a significant deficit, same-day neurology contact or emergency department assessment is the correct step.

B. Evidence — early high-efficacy DMT versus escalation

The shift in Australian and international practice

For most of the 2000s and 2010s, most neurologists followed an escalation strategy: start with a moderate-efficacy platform DMT; if the patient relapses on treatment, move to a more potent agent. The rationale was to avoid intensive immunosuppression in patients whose disease might remain mild on safer treatments.

Contemporary evidence has substantially shifted this position. The ANZAN DMT consensus 2024 — the Australian and New Zealand Neurological Association’s position statement — now reflects a preference for early high-efficacy treatment in active RRMS.

The key evidence:

Brown JAMA 2019 — The MSBase international registry cohort enrolled 1,555 propensity-matched patients across 30+ centres. Those started on high-efficacy DMT had significantly lower rates of conversion to SPMS and lower disability accumulation over a median 7.4-year follow-up, compared with those who escalated from platform therapy.

SUNRISE trial (Filippi NEJM 2025) — randomised confirmation: early high-efficacy DMT was superior to early moderate-efficacy DMT on a composite disability-and-relapse-activity endpoint in newly diagnosed active RRMS.

DELIVER-MS and TREAT-MS — two UK/US pragmatic randomised trials of induction versus escalation strategies, both published from 2023–2025, broadly supportive of the induction approach in active disease.

The caveat is shared decision-making: a patient with lower disease activity, strong concerns about immunosuppression, or imminent pregnancy planning may reasonably prefer a platform DMT with an agreed review plan. The ANZAN framework requires individualised risk–benefit discussion documented in the clinical record.

Ocrelizumab in PPMS

PPMS presents a specific challenge. Before ocrelizumab, no DMT had ever demonstrated efficacy in a phase III PPMS trial. The ORATORIO trial (Montalban NEJM 2017) showed ocrelizumab reduced 24-week confirmed disability progression by ~24% versus placebo. The effect was modest in absolute terms but represented a breakthrough. PBS Authority access for PPMS requires evidence of inflammatory features (gadolinium-enhancing lesions or recent MRI activity) and age criteria — your neurologist will determine eligibility.

Natalizumab and PML risk stratification

Natalizumab reduces RRMS relapse rate by approximately 68%, making it one of the most effective DMTs, but it carries a risk of progressive multifocal leukoencephalopathy (PML) — a rare, potentially fatal brain infection caused by JC virus. The risk is stratified by JCV antibody index, duration of natalizumab treatment, and prior immunosuppression. JCV-seronegative patients have very low PML risk; JCV-seropositive patients with more than 24 months of treatment and prior immunosuppression may face a risk of approximately 1 in 300. JCV antibody index monitoring every six months is mandatory, with planned treatment switches around the 24-month mark in JCV-positive patients.

C. Symptom and comorbidity management — the GP’s daily work

Most of the day-to-day MS work that arrives in a general practice consultation is about managing the symptoms and comorbidities that sit alongside DMT, not about prescribing DMT itself.

Fatigue is the most common and functionally disabling MS symptom. Assess for and treat comorbid sleep disorders — obstructive sleep apnoea is more prevalent in MS and is a powerful driver of fatigue when present. Screen and treat depression (below). Aerobic and resistance exercise, guided by a physiotherapist, is the best-evidenced fatigue intervention per eTG Neurology. Modafinil is used off-label in specialist practice; it is not PBS-funded for MS fatigue.

Bladder and UTI surveillance should be part of every GP review. Overactive bladder (urgency, frequency, urge incontinence): mirabegron is preferred over anticholinergics because of the lower cognitive burden — anticholinergic effects in people with MS-related cognitive slowing can be significant. Pelvic floor physiotherapy and continence nurse specialist review are first-line adjuncts. Urinary retention from a hypotonic bladder requires intermittent self-catheterisation training. A low threshold for urine MC&S at any suggestion of infection is appropriate — treat UTI promptly, culture-guided.

Spasticity: baclofen and tizanidine are the mainstay. Nabiximols (Sativex) is TGA-listed for refractory MS spasticity and can be prescribed by a GP under the Schedule 8 pathway after specialist initiation; however, PBS funding remains limited in 2026.

Depression and anxiety: approximately 50% lifetime prevalence of major depression in MS, with elevated suicide risk. A mental health care plan (MBS items 2715/2717) should be considered as the default for all patients with established MS. CBT, SSRI/SNRI, and combined approaches are all appropriate per eTG Psychotropic. Direct, non-alarmist assessment of suicidal ideation at every review is appropriate clinical practice.

Bone health: methylprednisolone given repeatedly for acute relapses contributes to cumulative steroid osteoporosis. Ensure vitamin D correction (target 25(OH)D >75 nmol/L), calcium 1,000–1,300 mg/day, and weight-bearing exercise. DEXA scanning is warranted in patients with frequent relapse-treatment requirements or significantly reduced mobility. Treat osteoporosis per Osteoporosis Australia guidelines.

Fampridine (dalfampridine): PBS Authority for MS-related walking impairment; prescribe after demonstrated response on a supervised trial, per the neurologist’s recommendation.

D. Australian operations

PBS Section 100 — Highly Specialised Drugs

All PBS-listed MS DMTs require Authority — Section 100 Highly Specialised Drugs program. Initiation requires a neurologist’s Authority prescription. GPs may continue prescribing on subsequent Authority scripts in many cases, once the neurologist has established and documented the Authority. Per pbs.gov.au:

• Moderate-efficacy DMTs: interferon-β preparations (Avonex, Rebif, Betaferon, Plegridy), glatiramer (Copaxone), teriflunomide (Aubagio), dimethyl/diroximel fumarate — Authority Required for RRMS.
• High-efficacy DMTs: ocrelizumab, ofatumumab, natalizumab (with mandatory JCV documentation), fingolimod/ozanimod/ponesimod, cladribine — Authority Required for RRMS.
• Siponimod (Mayzent): Authority Required for active SPMS meeting defined EDSS and disease activity criteria.
• Ocrelizumab for PPMS: Authority Required; requires evidence of inflammatory activity (gadolinium-enhancing lesions or documented recent MRI activity) and age criteria.
• Methylprednisolone IV: Compounded (Section 100) or oral high-dose PBS general for acute relapse treatment.
• Fampridine: Authority Required; demonstrated walking response on a supervised trial.

Important note: eculizumab, satralizumab, and inebilizumab are PBS-listed for NMOSD (aquaporin-4-IgG-positive disease), not for MS — confirm AQP4 serology before initiating any DMT in atypical cases, as treatment for NMOSD is different from and can be harmful in MS.

MBS items in general practice

Per MBS Online, relevant items include:

• Standard consultations: 23 / 36 / 44.
• GPCCMP (post-July-2025 Chronic Disease Management Plan): preparation item 965, review item 967. MS is a defining chronic condition. Reviews every three months are appropriate for active or complex disease; the plan enables allied-health referrals — physiotherapy, OT, psychology, exercise physiology, continence nursing.
• Mental Health Care Plan: items 2715 / 2717 — 50% lifetime depression prevalence makes this standard of care.
• Case conferencing: items 132 / 133 for multi-provider shared care.
• Telehealth: the existing-relationship rule is met by established MS shared care; video preferred for cognitive and affect assessment.

NDIS, aged care, and driving

Under-65 patients with significant disability are potentially eligible for NDIS funding on functional grounds — a detailed neurologist letter plus functional capacity assessment are required, with scope for home modifications, assistive technology, personal care, and supported accommodation.

Over-65: My Aged Care / Home Care Packages / Commonwealth Home Support Programme.

Driving fitness: Austroads Assessing Fitness to Drive 2022 applies case-by-case — visual, cognitive, motor function, and fatigue are all assessed. Patients carry a legal obligation to notify their state driver-licensing authority of their MS diagnosis. An OT driving assessment is often the most useful clinical step; NDIS may fund it.

E. Special populations

Pregnancy and DMT. Relapse rate falls during the second and third trimesters (immune tolerance effect) but rebounds sharply in the first three months postpartum — the PRIMS study (Confavreux NEJM 1998) quantified this clearly. Planning requires a neurologist–GP joint conversation well before conception. Glatiramer and interferon-β are the safest options during pregnancy. Teriflunomide and fingolimod require wash-out before conception. Natalizumab can be continued to approximately 34 weeks with careful postpartum planning; anti-CD20 therapies are typically paused preconception with attention to depletion timing. Prescribe folic acid 5 mg pre-conception and through the first trimester. Breastfeeding is generally compatible with glatiramer, interferon-β, and — on current data — anti-CD20 monoclonals.

Older adults with SPMS or PPMS. Onset of PPMS is later (mean ~40 years); SPMS affects increasing numbers in midlife and beyond. Balance DMT immunosuppression against cumulative comorbidity risk — ischaemic heart disease, renal impairment, and diabetes all narrow the safety margin of some DMTs. Pneumococcal, Shingrix, influenza, and COVID-19 vaccinations are especially important in this group given reduced baseline immune reserve.

Aboriginal and Torres Strait Islander peoples. MS prevalence is lower overall (latitude and genetic factors), but those affected may face greater barriers to early diagnosis and specialist access. The ATSI health assessment (MBS item 715) is applicable. Care coordination via NDIS, community-controlled health organisations, and GP-led shared care is often the most effective model.

Adolescents and paediatric MS. Approximately 5% of MS onset is before 18 — characterised by higher inflammatory burden and faster relapse rates than adult-onset MS, though with somewhat slower long-term disability accumulation. Managed at paediatric neurology centres. GP coordination, school-based support planning, and proactive mental health care are central.

EBV and the emerging prevention horizon. Bjornevik Science 2022 demonstrated a 32-fold increase in MS risk after Epstein-Barr virus seroconversion in a large US military cohort, providing strong causal evidence for EBV as a necessary precursor to MS. Phase II EBV vaccine trials are underway; this is a watch-the-space development, not yet practice-changing.

When to escalate

Urgent — same-day neurology contact or emergency department:

• Suspected acute relapse with significant deficit (significant limb weakness, sudden visual loss, acute gait failure, urinary retention) — requires same-day neurologist assessment for steroid decision.
• Cognitive or behavioural change, or any new focal deficit, in a patient on natalizumab — PML must be excluded urgently by neurologist-directed MRI ± CSF JCV PCR.
• Acute suicidal ideation.
• Febrile neutropenia or severe infection on immunosuppressive DMT (cladribine, alemtuzumab).

Semi-urgent — within days to weeks:

• Suspected breakthrough relapse on DMT — new clinical relapse or new MRI activity.
• DMT adverse effects: hepatotoxicity on teriflunomide, macular oedema on fingolimod, severe or persistent lymphopenia on fumarates.
• Pregnancy planning — DMT review must occur before conception.
• JCV antibody index rising toward 1.5 in a natalizumab-treated patient — plan treatment switch.

Routine — next available:

• Annual neurology review for stable, well-controlled disease.
• Initiation of GPCCMP and allied-health referrals.
• Driving fitness assessment.
• Vaccination update and bone health review.

What this article is and is not

This is general health information drawn from current Australian guidelines — Therapeutic Guidelines (eTG), ANZAN DMT consensus 2024, NICE NG220, AMH, and MS Australia clinical resources. It is not personal medical advice and does not replace a neurologist’s assessment, their individualised DMT decision, or your GP’s clinical judgement. All PBS DMT prescribing requires a specialist Authority prescription.

For Australian consumer information: MS Australia, MS Plus, HealthDirect — Multiple sclerosis, Better Health Channel.

For acute mental-health crisis: Lifeline 13 11 14, Beyond Blue 1300 22 4636, 13YARN 13 92 76 (First Nations).

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Sources cited

1. Therapeutic Guidelines (eTG) — Neurology: Multiple sclerosis
2. ANZAN — DMT consensus and shared-care position statements 2024
3. MS Australia — clinical resources
4. MS Plus
5. MSBase international registry
6. Australian Immunisation Handbook — NCIRS/ATAGI 2024
7. NICE NG220 — Multiple sclerosis in adults: management (2022)
8. Australian Medicines Handbook (AMH)
9. RACGP
10. PBS — MS DMT Section 100 Authority Required
11. MBS Online — neurology and CDM items
12. HealthDirect — Multiple sclerosis
13. Better Health Channel — Multiple sclerosis
14. Hauser SL et al. — Ocrelizumab versus interferon beta-1a (OPERA I/II, NEJM 2017)
15. Montalban X et al. — Ocrelizumab versus placebo in PPMS (ORATORIO, NEJM 2017)
16. Brown JWL et al. — Initial DMT and long-term outcomes in RRMS (JAMA 2019)
17. Kappos L et al. — Siponimod versus placebo in SPMS (EXPAND, Lancet 2018)
18. Burt RK et al. — HSCT versus DMT in RRMS (MIST, JAMA 2019)
19. Bjornevik K et al. — Epstein-Barr virus and MS (Science 2022)
20. Confavreux C et al. — Relapse rate during and after pregnancy in MS (PRIMS, NEJM 1998)
21. Austroads — Assessing Fitness to Drive 2022