Neurology AdvisorEscalation vs. Early Aggressive Treatment in Multiple Sclerosis

A Clinician Point-of-View with Dr. Yinan Zhang from Ohio State University

In the realm of multiple sclerosis (MS) treatment, the debate between early aggressive therapy and escalation therapy continues to evolve. With emerging evidence suggesting the potential benefits of early intervention with high-efficacy disease-modifying therapies (DMTs), physicians are encouraged to consider a nuanced approach that takes into account individual patient factors such as age, disease activity, and comorbidities. This article delves into the intricacies of these treatment strategies, offering insights from Dr. Yinan Zhang, an expert in the field, to guide clinicians in optimizing care for patients with relapsing-remitting MS (RRMS).

Key Points:

• Early aggressive treatment in MS aims to suppress disease activity at the onset to prevent disability progression and the transition from RRMS to secondary progressive MS (SPMS).
• Young patients with active disease and numerous T2 lesions benefit most from early aggressive treatment compared to escalation therapy.
• High-efficacy DMTs used in early aggressive treatment, such as anti-CD20 agents, natalizumab, and S1P receptor modulators, generally offer a better safety profile than induction therapies like mitoxantrone and cladribine.
• The decision between early aggressive therapy and escalation therapy hinges on factors like patient age, disease activity, and risk tolerance for potential side effects.
• Real-world safety data, biomarkers for disease monitoring, and research on DMT discontinuation and access disparities are needed to refine early aggressive treatment strategies.
• For patients with high disease activity or risk of progression, early aggressive treatment is preferred over starting with moderate-efficacy DMTs.
• Induction therapies, although potent, are often reserved due to their safety profiles, with patient preference and monitoring requirements guiding DMT selection.
• Continuous monitoring for adverse effects, disease progression, and treatment response is crucial in managing MS with early aggressive treatment.
• Patients rarely switch from one high-efficacy DMT to another due to breakthrough disease; switches are more often motivated by safety concerns.

“DMTs in the high-efficacy treatment category, such as anti-CD20 agents, natalizumab, and S1P receptor modulators, have all been shown in multiple phase 3 trials to have a marked reduction in the annualized relapse rate compared to placebo or an active comparator drug, with real-world data confirming low relapse rates.”
– Yinan Zhang, MD, Ohio State University, Wexner Medical Center, Columbus, OH

More on Multiple Sclerosis