Early High-Efficacy Therapy in Multiple Sclerosis

Rationale for Shifting from Stepped Care to Early Escalation

• The European Academy of Neurology-ECTRIMS recommends targeting inflammation early in the disease course, shifting from a stepped care approach to an early escalation and induction strategy 1, 2

Specific Outcomes Targeted

Prevention of Irreversible Neurological Damage

• High-efficacy disease-modifying therapies (DMTs) are more effective when started early in the disease course, including alemtuzumab, natalizumab, ocrelizumab, ofatumumab, and cladribine 2, 3
• Treatment at a younger age and after fewer prior DMTs is associated with a lower rate of long-term progression 2, 3

Indications for Early High-Efficacy Therapy

Patients with Aggressive Disease

• For patients with markers of aggressive disease, high-efficacy therapy should be considered as first-line treatment: frequent relapses with incomplete recovery 2, high frequency of new MRI lesions 2, rapid onset of disability 2, age <45 years with disease duration <10 years 5, and EDSS score <4.0 with high focal inflammation 1, 2

Practical Decision Algorithm

• For newly diagnosed RRMS patients, evaluate markers of disease aggressiveness (relapse frequency, recovery from relapses, MRI activity, onset of disability) and start high-efficacy DMT immediately if ≥2 aggressive markers are present 1, 2
• If the disease is highly active but does not meet aggressive criteria, consider high-efficacy DMT as first-line or early escalation after a short period of moderate-efficacy therapy 1, 2