This article provides an evidence-based approach to the management of patients with early relapsing multiple sclerosis (MS).
Numerous clinical trials have shown the role of disease-modifying therapies in reducing relapses and new MRI lesions in patients with relapsing MS. Many of these trials also show the ability of these agents to delay disability progression, and a few suggest that disease-modifying therapies may slow brain atrophy in relapsing MS; however, very few suggest that disease-modifying therapies can improve symptoms or disability. The therapeutic armamentarium of disease-modifying therapies includes five interferon formulations, two versions of glatiramer acetate, mitoxantrone, natalizumab, fingolimod, teriflunomide, dimethyl fumarate, and alemtuzumab.
Although multiple disease-modifying therapies exist, the risks of these vary markedly, head-to-head comparator trials are limited, and no prospective biomarkers for treatment efficacy exist; therefore, choosing a disease-modifying therapy for an individual patient with MS is a difficult decision. This difficulty is compounded by limitations in predicting a patient’s disease course, and the risk tolerance of the patient and opinions of the care partner need to be factored into the decision analysis as well. After a disease-modifying therapy is chosen, vigilance for clinical or radiographic breakthrough disease is very important, as this may suggest a suboptimal response to the chosen therapy. Furthermore, the role of symptom management and wellness should always remain part of the approach to the patient with MS.
Address correspondence to Dr David E. Jones, University of Virginia, Department of Neurology, PO Box 800394, Charlottesville, VA 22908, Dj9d@virginia.edu.
Relationship Disclosure: Dr Jones serves as cochair of the advocacy committee of the Consortium of Multiple Sclerosis Centers and codirector of the North American Registry for Care and Research Committee in Multiple Sclerosis (NARCRMS); on the advisory boards of the American Academy of Neurology for disease-modifying therapy guidelines and the Consortium of Multiple Sclerosis Centers for MRI guidelines; on the Multiple Sclerosis Association of America Healthcare Advisory Committee and the Multiple Sclerosis Foundation Healthcare Advisory Panel; and as a consultant for Biogen, Novartis AG, the Pharmacy Quality Alliance, and Sanofi Genzyme. Dr Jones has received honoraria for CME activities from the Consortium of Multiple Sclerosis Centers, Johns Hopkins University, the Virginia Neurologic Society, and the University of Massachusetts. Dr Jones has received research support from Biogen and the National Multiple Sclerosis Society and has provided expert legal testimony.
Unlabeled Use of Products/Investigational Use Disclosure: Dr Jones reports no disclosure.