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. 2025 May 19;7(1):33.
doi: 10.1186/s42466-025-00387-y.

From routine to selective: how updated MRI guidelines reshape gadolinium use in Germany

Marc Pawlitzki  1 , Alexander Stahmann  2 , Niklas Frahm  2 , Mathia Kirstein  2 , Melanie Peters  2   3 , Peter Flachenecker  4 , Tim Friede  5 , Kerstin Hellwig  6 , Dagmar Krefting  7 , Michaela Mai  8 , Clemens Warnke  9 , Uwe K Zettl  10 , David Ellenberger  2
Affiliations

From routine to selective: how updated MRI guidelines reshape gadolinium use in Germany

Marc Pawlitzki et al. Neurol Res Pract. .

Abstract

Magnetic resonance imaging (MRI) is a critical diagnostic tool and monitoring modality for multiple sclerosis (MS), frequently employing gadolinium-based contrast agents (Gd). However, concerns regarding the accumulation of Gd have prompted international guidelines (MAGNIMS-CMSC-NAIMS, 2021) to advocate for the limitation of Gd utilization. Consequently, we assessed of the impact of the 2021 guidelines on the use of Gd in MRI in MS patients in Germany by conducting a retrospective analysis of MRI data from 12,833 MS patients in the German MS Register (2019-2024). Generalized additive models were employed to analyze Gd use trends over time by MRI type (cranial, spinal, combined). From 2020 to 2024, a significant decline in Gd use was observed, with percentages dropping from 74.2 to 41.2% in cranial MRI, from 78.2 to 39.2% in spinal MRI and from 81.8 to 59.0% in combined MRI (p < 0.001). The most substantial decline occurred within the initial five years of MS. Gd use in MS MRI scans has significantly decreased in line with the updated guidelines. Nevertheless, its persistent utilization in over one-third of cases necessitates further examination.

Keywords: Gadolinium-based contrast; Magnetic resonance imaging; Relapsing multiple sclerosis.

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Conflict of interest statement

Declarations. Ethics approval and consent to participate: The registration of the GMSR took place at the German Register for Clinical Trials [Deutsches Register Klinischer Studien (DRKS); No. DRKS00011257]. The initial ethics vote was approved by University of Würzburg’s institutional review board (Permit No. 142/12). All participants provided written consent for the utilization of their anonymized data for research purposes. Consent for publication: Not applicable. Competing interests: Marc Pawlitzki received honoraria for lecturing and travel expenses for attending meetings from Alexion, ArgenX, Bayer Health Care, Biogen, Hexal, Merck Serono, Novartis, Roche, Sanofi-Aventis, Takeda and Teva. His research is funded by ArgenX, Biogen, Demecan, Hexal, Horizon Merck Serono, Novartis, Roche, Viatris, Takeda and Teva. Niklas Frahm is an employee of the GMSR. Moreover, he is an employee of Rostock’s University Medical Center and received travel funds for research meetings from Novartis. None resulted in a conflict of interest. Melanie Peters, David Ellenberger and Mathia Kirstein had no personal financial interests to disclose other than being employees of the GMSR. Alexander Stahmann has no personal financial interests to disclose, other than being the leader of the GMSR, which receives (project) funding from a range of public and corporate sponsors, recently including G-BA, The German Retirement Insurance, The German MS Trust, German MS Society, Bristol-Myers Squibb, Merck, Novartis, Roche and TG/Neuraxpharm, all outside this study. Peter Flachenecker has received speaker’s fees and honoraria for advisory boards from Almirall, Bayer, Biogen Idec, BMS-Celgene, Coloplast, Genzyme, GW Pharma, Hexal, Janssen-Cilag, Novartis, Merck, Roche, Sanofi, Stadapharm and Teva. None resulted in a conflict of interest. Tim Friede has received personal fees for statistical consultancies (including data monitoring committees) from Actimed, Aslan, Bayer, BiosenseWebster, BMS, CSL Behring, Daiichi Sankyo, Enanta, Fresenius Kabi, Galapagos, IQVIA, Immunic, KyowaKirin, LivaNova, Minoryx, Novartis, PINK! gegen Brustkrebs, PPD, RECARDIO, Recordati, Relaxera, Roche, Servier, Viatris, Vifor and VICO Therapeutics. Kerstin Hellwig has received speaking fees and/or institutional grant support from Bayer, Biogen, BMS, Merck Serono, Novartis, Roche, Sanofi-Genzyme and Teva. None resulted in a conflict of interest. Dagmar Krefting has nothing to disclose. Michaela Mai is an employee of the German MS Society, federal association, which receives funding from a range of public and corporate sponsors, recently including BMG, G-BA, The German MS Trust, Biogen, BMS, Merck Serono, Novartis, Roche, Sanofi and Viatris. None resulted in a conflict of interest. Clemens Warnke has received institutional support from Novartis, Alexion, Sanofi Genzyme, Biogen, Merck and Roche. None resulted in a conflict of interest. Uwe K. Zettl has received speaking fees, travel support and /or financial support for research activities from Alexion, Almirall, Bayer, Biogen, Bristol Myers Squibb, Janssen, Merck Serono, Novartis, Octapharma, Roche, Sanofi Genzyme, Teva as well as EU, BMBF, BMWi and DFG. None resulted in a conflict of interest.

Figures

Fig. 1
Fig. 1
Contrast agent use in MRI: Analysis by MRI type, location, year, and disease duration since 2019. (a) Frequency of Gd administration in MRI examinations by type/location of examination and calendar year. The shaded areas represent the associated 95% confidence intervals. (b) Frequency of contrast agent administration in MRI examinations broken down by type/location of examination and duration of disease. The shaded areas represent the corresponding 95% confidence intervals. (c) Venn diagram of MRI examinations since January 1, 2019 by type: cranial vs. spinal separated by with vs. without contrast agent administration. *There are 61 MRI examinations in which both a cranial and a spinal MRI were performed, but Gd was only used in one type of MRI (Gd may have been given between both MRI). These rare cases were excluded from further analyses. Gd– Gadolinium-based contrast agents; MRI– Magnetic Resonance Imaging
See this image and copyright information in PMC

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