Abstract
Two different treatment paradigms are most often used in multiple sclerosis (MS). An escalation or induction approach is considered when treating a patient early in the disease course. An escalator prioritizes safety, whereas an inducer would favor efficacy. Our understanding of MS pathophysiology has evolved with novel in vivo and in vitro observations. The treatment landscape has also shifted significantly with the approval of over 10 new medications over the past decade alone. Here, we re-examine the treatment approach in light of these recent developments. We believe that recent work suggests that early prediction of the disease course is fraught, the amount of damage to the brain that MS causes is underappreciated, and its impact on patient function oftentimes is underestimated. These concerns, coupled with the recent availability of agents that allow a better therapeutic effect without compromising safety, lead us to believe that initiating higher efficacy treatments early is the best way to achieve the best possible long-term outcomes for people with MS.
Glossary
- DTI=
- diffusion tensor imaging;
- EDSS=
- Expanded Disability Status Scale;
- HETA=
- highly effective treatment early approach;
- IFN=
- interferon;
- MTR=
- magnetization transfer ratio;
- NARCOMS=
- North American Research Committee on Multiple Sclerosis;
- NEDA=
- no evidence of disease activity;
- NFL=
- neurofilament light;
- PCORI=
- Patient-Centered Outcomes Research Institute;
- PML=
- progressive multifocal leukoencephalopathy;
- SC=
- subcutaneous
Footnotes
Go to Neurology.org/NN for full disclosures. Funding information is provided at the end of the article.
The Article Processing Charge was funded by the authors.
- Copyright © 2019 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American Academy of Neurology.
This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives License 4.0 (CC BY-NC-ND), which permits downloading and sharing the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.
Letters: Rapid online correspondence
- An argument for broad use of high efficacy treatments in early multiple sclerosis
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- Article
- Abstract
- Glossary
- Our ability to predict disease course at onset is limited
- Conventional clinical imaging can miss or underestimate ongoing damage
- MS is rarely benign over the long term when dysfunction is carefully interrogated
- Long-term follow-up studies of patients on platform agents reveal the risks of undertreatment
- Short-term comparison studies demonstrate superiority in reduction of relapses, MRI change, and disability progression for some agents
- The reported safety profiles of some highly effective agents do not currently materially differ from lower efficacy agents
- The challenges of patient preference and adherence, therapeutic inertia, and insurance coverage
- Early intervention might substantively alter disease course and prevent irreversible progression, whereas later treatment might not confer much benefit
- The perils of escalation
- The way forward
- Conclusion
- Study funding
- Disclosure
- Acknowledgment
- Appendix Authors
- Footnotes
- References
- Figures & Data
- Info & Disclosures
