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Over the last two decades, thanks to the discovery of several pharmaceutical agents, multiple sclerosis (MS) has been transformed into a treatable disorder although the degree of therapeutic response may vary considerably. As more medications find their entry into the MS market, a clinician faces a mounting challenge of comparing risk and benefit profiles of various agents in an attempt to find the best treatment approach for each individual patient. In this review, we aim to summarize the available data on safety profiles of available MS therapies while focusing mostly on serious medication specific potential adverse events without discussing the teratogenic potential of each agent (unless there is a black box warning) or hypersensitivity reactions. Our goal is to provide a clinician with guidance on assuring the appropriate safety monitoring for patients treated with one of the agents discussed. We also comment on the future of risk management in MS and discuss possible enhancements to the current model of drug approval process and general strategies to improve the patient safety.

Recent studies have demonstrated the immunomodulatory properties of vitamin D, and vitamin D deficiency may be a risk factor for the development of MS. The risk of developing MS has, in fact, been associated with rising latitudes, past exposure to sun and serum vitamin D status. Serum 25-hydroxyvitamin D [25(OH)D] levels have also been associated with relapses and disability progression. The identification of risk factors, such as vitamin D deficiency, in MS may provide an opportunity to improve current treatment strategies, through combination therapy with established MS treatments. Accordingly, vitamin D may play a role in MS therapy. Small clinical studies of vitamin D supplementation in patients with MS have reported positive immunomodulatory effects, reduced relapse rates and a reduction in the number of gadolinium-enhancing lesions. However, large randomized clinical trials of vitamin D supplementation in patients with MS are lacking. SOLAR (Supplementation of VigantOL (R) oil versus placebo as Add-on in patients with relapsing-remitting multiple sclerosis receiving Rebif (R) treatment) is a 96-week, three-arm, multicenter, double-blind, randomized, placebo-controlled, Phase II trial (NCT01285401). SOLAR will evaluate the efficacy of vitamin D-3 as add-on therapy to subcutaneous interferon beta-1a in patients with RRMS. Recruitment began in February 2011 and is aimed to take place over 1 calendar year due to the potential influence of seasonal differences in 25(OH)D levels.

Using a published protocol, we evaluated a non-selected population of stroke patients to identify unnecessary days of hospitalisation in the Department of Neurology at the Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland. This study was undertaken to determine whether physicians can modify the non-medically justified hospital days. We prospectively studied 118 patients with stroke admitted to our Department over a period of 5 months. Each day spent on the ward was placed in one of two categories: those due to medical reasons (1,391 hospital days) and those due to non-medical reason (518 days). Using a previously published protocol, 74 parameters were evaluated. Delays in obtaining examinations or a specialist's consultation accounted for a small proportion of waiting days (1.9% of total hospital days), which was greater in patients who were not disabled (0.9% of hospital days) than in patients with total dependence (0.2% of hospital days). The delays resulted mainly from awaiting transfer either to another department or to a nursing home. The length of stay increased with severity of dependence. However, the number of days spent for transfer to a nursing home was also relatively high in the non-dependent patient group (42% of hospital days). This study demonstrates that neurologists cannot easily influence the length of stay in hospital. It also corroborates the need to develop short- and long-term chronic care facilities to facilitate the transfer of patients once there are no further medical reasons for staying in hospital.