Multiple sclerosis (MS) is the most common chronic neuroimmunological disease in Australian adults. Around 33,000 Australians live with MS today — most diagnosed between 20 and 40, with women affected approximately three times as often as men.
Importantly, the way MS is treated has changed beyond recognition over the last decade: where the 2010 toolkit was a small number of moderately-effective injectable medications, the 2026 toolkit includes a dozen high-efficacy disease-modifying therapies, several of which can be expected to suppress relapses almost entirely and slow long-term disability progression substantially. This page covers what MS is, how it is diagnosed in 2026, what the current treatment options are, and how MS is managed at East Neurology in Bondi Junction.
What is multiple sclerosis?
MS is an autoimmune disease in which the immune system attacks myelin — the insulating coating around nerve fibres in the central nervous system. Damage to myelin slows or blocks the electrical signals running through those nerves, producing the symptoms that define MS: loss of vision, weakness, numbness, dizziness, bladder symptoms, cognitive change, fatigue.
MS is relapsing in around 85% of patients at onset — episodes of new neurological symptoms separated by periods of partial or complete recovery — and progressive from onset in the remaining 15% (primary progressive MS). Over time, most relapsing patients can develop a secondary progressive phase if disease activity is not well controlled. Modern early high-efficacy treatment is specifically aimed at preventing this transition.
How is MS diagnosed?
The diagnostic criteria — the McDonald criteria (currently 2017 revision, with 2024 updates incorporating central vein sign and paramagnetic rim lesions) — require evidence of central nervous system damage disseminated in space (more than one location) and disseminated in time (more than one episode, or specific MRI markers of older + newer damage).
The diagnostic workup typically includes:
🩺 Clinical history and examination
Episodes of neurological symptoms lasting more than 24 hours, with at least partial recovery. Common first presentations include optic neuritis (painful vision loss in one eye, typically over hours to days), transverse myelitis (numbness or weakness from a band-like level), brainstem syndromes (double vision, vertigo, facial numbness), and isolated sensory or cerebellar symptoms.
🧲 MRI brain and spinal cord
Modern MS-protocol MRI (magnetic resonance imaging) is the most important investigation. Characteristic features include:
- Periventricular lesions — often ovoid, perpendicular to the ventricles (Dawson’s fingers)
- Juxtacortical lesions touching the cortex
- Infratentorial lesions — brainstem and cerebellum
- Spinal cord lesions — short-segment, often dorsal-column
- Gadolinium-enhancing lesions — active inflammation
- Central vein sign — modern marker that helps distinguish MS from mimics like vascular small-vessel disease
For patients told they have “white spots on the MRI,” our dedicated page on what those mean walks through the differential.
💧 Cerebrospinal fluid (CSF) analysis
- Oligoclonal bands (OCBs) — present in over 95% of MS patients, only ~5% of controls. The single most useful CSF test.
- IgG index — elevated
- Kappa free light chains — emerging marker
A lumbar puncture is not always required if the clinical picture and MRI are unambiguous, but is commonly performed to confirm and to exclude mimics.
👁️ Visual evoked potentials
Helpful when subclinical optic nerve involvement is suspected.
🩸 Bloods to exclude mimics
NMO/MOG antibodies, vitamin B12, syphilis serology, HIV, ANA, ANCA, copper, thyroid function — all checked to rule out conditions that can mimic MS.
The 2026 treatment era
Modern MS treatment is built around disease-modifying therapy (DMT) — drugs that reduce relapse rate, MRI activity, and long-term disability progression. The 2026 Australian landscape includes:
High-efficacy first-line DMTs (the modern standard for most patients)
| Drug | Class | Route | Frequency |
|---|---|---|---|
| Ocrelizumab (Ocrevus) | Anti-CD20 monoclonal | IV | 6-monthly |
| Ofatumumab (Kesimpta) | Anti-CD20 monoclonal | Subcutaneous | Monthly self-injection |
| Ublituximab (Briumvi) | Anti-CD20 monoclonal | IV | 6-monthly |
| Natalizumab (Tysabri) | Anti-α4 integrin | IV or SC | 4-weekly |
| Cladribine (Mavenclad) | Selective lymphocyte depletion | Oral | 2 short courses over 2 years |
For most patients newly diagnosed with active relapsing MS, the modern recommendation is to start with a high-efficacy therapy from the outset, rather than escalating from milder agents. Multiple large studies have shown that early high-efficacy treatment produces better long-term outcomes than starting low and escalating later.
💊 S1P receptor modulators
Oral drugs that sequester lymphocytes in lymph nodes:
- Ozanimod (Zeposia)
- Ponesimod (Ponvory)
- Fingolimod (Gilenya) — original of the class
🗂️ Older but still used agents
- Dimethyl fumarate (Tecfidera) — for milder disease or specific contraindications
- Teriflunomide (Aubagio) — once-daily oral
- Interferon beta and glatiramer acetate — now largely superseded but used in specific scenarios (e.g. pregnancy planning, mild stable disease)
🔬 Autologous haematopoietic stem cell transplantation (AHSCT)
For highly active MS with breakthrough disease on multiple high-efficacy DMTs, AHSCT is now an established option, with Australian centres in Sydney and Melbourne accepting referrals. Five-year disease-free survival in carefully selected patients exceeds 70%.
🔭 BTK inhibitors (emerging)
Tolebrutinib has now been approved by the TGA (Therapeutic Goods Administration) for secondary progressive MS (SPMS) — a significant step, as it targets the smouldering inflammation that drives progression. It is not yet PBS (Pharmaceutical Benefits Scheme) listed, but a special access pathway is likely in the interim. Other BTK (Bruton tyrosine kinase) inhibitors — evobrutinib, fenebrutinib and related agents — remain in or are completing Phase 3 trials for relapsing and progressive MS.
With modern high-efficacy treatment started early, the majority of relapsing MS patients can expect long-term mobility preservation. The natural history of MS is dramatically different in the modern treatment era from what older data suggest.
Symptomatic management
Disease-modifying therapy controls the immune attack. Symptom management addresses what MS leaves behind:
- Fatigue — the most common symptom; managed with energy-conservation strategies, treatment of comorbid depression and sleep apnoea, and trialled medications (modafinil, amantadine)
- Spasticity — physiotherapy, baclofen, tizanidine, botulinum toxin for focal spasticity
- Bladder dysfunction — urodynamic assessment, anticholinergics, mirabegron, beta-3 agonists, intermittent self-catheterisation
- Cognitive symptoms — formal neuropsychological assessment + cognitive rehabilitation
- Mood — depression and anxiety are common; treatment is straightforward and effective
- Optic neuritis (acute) — high-dose IV methylprednisolone shortens recovery time (but does not affect long-term outcome)
- Pain — neuropathic pain (anticonvulsants), musculoskeletal pain (physiotherapy), trigeminal neuralgia (specific protocols)
Pregnancy and MS
A major focus of modern MS care. Key points:
- Relapse rate falls in pregnancy — particularly the second and third trimesters
- Post-partum relapse risk rises — peaks at 3–6 months after delivery
- DMT compatibility with pregnancy and breastfeeding varies — ocrelizumab, ofatumumab, and natalizumab have evolving data; cladribine has specific timing considerations; S1P modulators must be stopped before conception
- Pre-conception counselling is essential — at least 6 months before planned conception, and ideally as part of the discussion when DMT is first chosen
Dr Koren and Dr Granot work with you and your obstetrician to optimise both disease control and pregnancy planning.
Comorbidities and lifestyle
MS rarely exists in isolation. Modern care actively addresses:
☀️ Vitamin D
Supplementation to >75 nmol/L is standard recommendation.
🚭 Smoking cessation
Smoking accelerates MS progression; the evidence is now strong enough that this is treated as a disease-modifying intervention.
🏃 Exercise
Regular aerobic and resistance training improves fatigue, mood, and (in some studies) MRI outcomes.
🥗 Diet
No specific MS diet has been validated, but Mediterranean-pattern eating is supported.
😴 Sleep apnoea
Common and contributes to fatigue.
❤️ Vascular risk
Blood pressure, lipids, glycaemia — co-management with the GP.
How MS is managed at East Neurology
Dr Tal Koren leads the MS service at East Neurology, working with Dr Ron Granot’s wider team. The standard care pathway includes:
- Initial consultation — detailed history, examination, review of all prior MRIs and reports
- Investigations — MRI brain + spinal cord (often repeated with modern protocols if older scans were limited), CSF analysis, antibody panels, bloods
- Diagnosis confirmation — McDonald criteria assessment
- DMT discussion — shared decision-making with the patient, considering disease activity, lifestyle, pregnancy plans, comorbidities, route of administration preference, monitoring burden, and PBS access
- Treatment initiation — coordinated with infusion centres for IV therapies or prescription for oral/subcutaneous
- Monitoring — clinical review every 3–6 months, annual MRI brain (and spinal cord where indicated), blood monitoring per drug-specific schedule
- Multidisciplinary support — MS nurse referral, physiotherapy, neuropsychology, urodynamics, pelvic-floor physiotherapy as needed
Why see a neuroimmunology subspecialist for MS?
MS care has become technically complex. Choosing between a dozen high-efficacy therapies, deciding when to escalate, managing pregnancy planning, recognising the difference between a true relapse and a pseudo-relapse, interpreting evolving MRI changes against a known prior baseline — these are decisions that benefit from focused subspecialty experience. Dr Koren’s MPhil research work at the Brain and Mind Centre, University of Sydney is specifically on MRI biomarkers of MS progression, which sits at the heart of those decisions.
Frequently asked questions
Is MS hereditary?
There is a small genetic component — first-degree relatives of an MS patient have ~3% lifetime risk vs ~0.3% population baseline — but MS is not directly inherited. Most people with MS have no family history.
Will I end up in a wheelchair?
With modern high-efficacy treatment started early, the majority of relapsing MS patients can expect long-term mobility preservation. The natural history of MS is dramatically different in the modern treatment era from what older data suggest.
Can I have children?
Yes — MS is not a reason to avoid pregnancy. Modern practice manages DMT around pregnancy planning, and post-partum strategies minimise relapse risk.
Is there a cure?
There is no cure in the sense of fully restoring damaged myelin. There are highly effective treatments that suppress new disease activity, and significant research is underway on remyelination strategies.
Should I switch from my current DMT?
Only your treating neurologist can answer this with confidence. The general principle: if you are having relapses, new MRI activity, or significant side effects on your current therapy, a review is appropriate. Many patients on older therapies benefit from a discussion about modern higher-efficacy alternatives.
Can I see Dr Koren for an MS second opinion?
Yes. Patients already under another neurologist are welcome to request a second-opinion consultation, particularly when considering a DMT change or facing a difficult treatment decision.
Related reading on East Neurology
- Neuroimmunology — overview of conditions and team
- NMOSD — distinguishing from MS
- MOG-AD — another antibody-defined syndrome
- White spots on the MRI — what they mean
- Dr Tal Koren — Consultant Neurologist (Neuroimmunology)
External resources
- MS Australia — peak national patient organisation
- MS Plus (formerly MS Society NSW) — NSW-based services + connection
This page is general information about multiple sclerosis. It is not personal medical advice. To discuss your specific situation, request a referral from your GP to East Neurology — Bondi Junction, Sydney.
Book an appointment
Dr Tal Koren leads the MS service at East Neurology. Ask your GP for a referral, then get in touch — new patients and second opinions are welcome.
Or call 02 9388 0615. East Neurology is a private practice; we do not bulk bill (including DVA cardholders) — Medicare claims are processed for you on the day.