Early highly effective versus escalation treatment approaches in relapsing multiple sclerosis

Area of Science:

• Neurology
• Immunology
• Pharmacology

Background:

• Multiple sclerosis (MS) treatment decisions are complex due to numerous disease-modifying therapies (DMTs) with varied safety and efficacy.
• While early treatment is recognized as important, optimal initial treatment intensity for relapsing MS remains unknown.
• Current clinical trial evidence is limited for guiding initial DMT selection, complicated by patient risk tolerance and unpredictable treatment responses.

Purpose of the Study:

• To address the clinical dilemma of whether to initiate treatment with moderately effective, safer DMTs versus highly effective DMTs from the outset in relapsing MS.
• To highlight the lack of comparative effectiveness data for different initial treatment approaches in MS.

Main Methods:

• Review of existing clinical trial data and clinical practice considerations for initial DMT selection in relapsing MS.
• Identification of knowledge gaps regarding the comparative effectiveness of different treatment strategies.

Main Results:

• Substantial variability exists in current treatment selection for MS.
• Clinical trials have primarily focused on pairwise comparisons, not comprehensive treatment approaches.
• Evidence to guide the choice between escalating therapy and immediate high-efficacy treatment is weak.

Conclusions:

• More research, including pragmatic randomized clinical trials and observational studies, is essential.
• Future studies should aim to inform more rational selection of initial MS therapies.
• Improved initial treatment strategies have the potential to enhance the quality of life for patients with relapsing MS.