2024 Volume 41 Issue 4 Pages 582-587
In recent years, the development of disease–modifying drugs (DMD) has significantly expanded the treatment options for multiple sclerosis (MS), demonstrating the potential to suppress relapses and disability progression when initiating effective DMD early. However, evidence guiding the selection of DMD is still insufficient. Choosing the right DMD involves considering factors such as relapse frequency, severity, recovery extent, disability level, MRI lesion characteristics, DMD efficacy, safety, administration route, and patient preferences. Regular assessment of disease activity is crucial post–DMD initiation, aiming for “no evidence of disease activity” (NEDA) and prompt adjustment to more effective DMD if necessary. Clinical cases are presented to illustrate the decision–making process for DMD selection based on individual patient characteristics.
In the clinical setting, guidelines suggest considering interferonβ, glatiramer acetate, or dimethyl fumarate for patients with low relapse frequency, low MRI activity, and low disability. However, due to suboptimal efficacy and side effects, newer options like natalizumab and ofatumumab are often preferred. Escalation therapy, starting with lower efficacy DMD like dimethyl fumarate and escalating to higher efficacy therapies if needed, is emphasized for patients without poor prognostic factors. Early intensive therapy is recommended for patients with poor prognostic factors, starting with high–efficacy DMD like natalizumab or ofatumumab.
The decision to discontinue DMD in elderly patients remains under debate, with caution and careful observation required. The fundamental approach to MS treatment involves early intensive therapy, particularly with natalizumab or ofatumumab. The choice between them depends on factors like JC virus antibody status and age. Individualized assessment and continuous reevaluation of disease activity are essential for making informed decisions in MS management.
