title: Is it time to target no evident disease activity (NEDA) in multiple sclerosis?
abstract: The management of multiple sclerosis is becoming increasingly complex with the emergence of new and more effective disease-modifying therapies (DMT). We propose a new treatment paradigm that individualises treatment based on a choice between two interchangeable therapeutic strategies of maintenance-escalation or induction therapy. We propose treating- to-target of no evident disease activity (NEDA) as defined using clinical and MRI criteria. This algorithm requires active monitoring with a rebaselining MRI, at a point in time after the specific DMT concerned has had sufficient time to work, and at least annual MRI studies to monitor for subclinical relapses. Disease activity on the maintenance-escalation therapy arm of the algorithm indicates a sub-optimal treatment response and should trigger a discussion about switching, or escalating, therapy or the consideration of switching to the induction therapy arm of the algorithm. In comparison, disease activity on an induction therapy arm would be an indication for retreatment or a switch to the maintenance-escalation therapy arm. We envisage the definition of NEDA evolving with time as new technological innovations are adopted into clinical practice, for example the normalisation of whole, or regional, brain atrophy rates and cerebrospinal fluid neurofilament levels.
authors.affiliation: Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University London, 4 Newark Street, London E1 2AT, UK; Department of Neurology, Royal London Hospital, Barts Health NHS Trust, London, UK. Electronic address: g.giovannoni@qmul.ac.uk.
authors.forename: Gavin
authors.initials: G
authors.lastname: Giovannoni
authors.affiliation: Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University London, 4 Newark Street, London E1 2AT, UK; Department of Neurology, Royal London Hospital, Barts Health NHS Trust, London, UK. Electronic address: Benjamin.Turner@bartshealth.nhs.uk.
authors.forename: Benjamin
authors.initials: B
authors.lastname: Turner
authors.affiliation: Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University London, 4 Newark Street, London E1 2AT, UK; Department of Neurology, Royal London Hospital, Barts Health NHS Trust, London, UK. Electronic address: s.gnanapavan@qmul.ac.uk.
authors.forename: Sharmilee
authors.initials: S
authors.lastname: Gnanapavan
authors.affiliation: Department of Neuroradiology, Royal London Hospital, Barts Health NHS Trust, London, UK. Electronic address: Curtis.Offiah@bartshealth.nhs.uk.
authors.forename: Curtis
authors.initials: C
authors.lastname: Offiah
authors.affiliation: Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University London, 4 Newark Street, London E1 2AT, UK; Department of Neurology, Royal London Hospital, Barts Health NHS Trust, London, UK. Electronic address: k.schmierer@qmul.ac.uk.
authors.forename: Klaus
authors.initials: K
authors.lastname: Schmierer
authors.affiliation: Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University London, 4 Newark Street, London E1 2AT, UK; Department of Neurology, Royal London Hospital, Barts Health NHS Trust, London, UK. Electronic address: m.calado-marta@qmul.ac.uk.
authors.forename: Monica
authors.initials: M
authors.lastname: Marta
mesh_terms: D000465:Algorithms; D018450:Disease Progression; D006801:Humans; D008279:Magnetic Resonance Imaging; D009103:Multiple Sclerosis / Q000473:pathology / Q000503:physiopathology / Q000628:therapy*; D057285:Precision Medicine / Q000379:methods; D016896:Treatment Outcome
keywords: Disease activity free; Disease modifying therapy; Multiple sclerosis; NEDA; No evident disease activity; Treating to target