Optimizing therapy early in multiple sclerosis: An evidence-based view.
Therapies that target the underlying pathology of multiple sclerosis (MS), including focal and diffuse damage, may improve long-term disease control. Focal damage (inflammatory lesions) manifests clinically mainly as relapses, whereas diffuse damage (neurodegeneration and brain volume loss) has been more closely associated with disability progression and cognitive decline. Given that first-line therapies such as beta-interferon and glatiramer acetate, which are primarily directed against inflammation, might fail to adequately control disease activity in some patients, it has been recommended to switch these patients early to a therapy of higher efficacy, possibly targeting both components of MS pathology more rigorously. This review provides an overview of the efficacy of EU-approved disease-modifying therapies on conventional MS outcome measures (relapses, disability progression and paraclinical magnetic resonance imaging endpoints) in addition to brain volume loss, a measure of diffuse damage in the brain. In addition, the evidence supporting early treatment optimization in patients with high disease activity despite first-line therapy will be reviewed and an algorithm for optimal disease control will be presented.
Department of Neurology, MS Center Dresden, Center of Clinical Neuroscience, University Hospital Carl Gustav Carus, Dresden University of Technology, Fetscherstr. 74, 01307 Dresden, Germany. Electronic address: Tjalf.Ziemssen@uniklinikum-dresden.de.
Tjalf
T
Ziemssen
Department of Medicine, Surgery and Neuroscience, University of Siena, Viale Bracci 2, Siena 53100, Italy. Electronic address: destefano@unisi.it.
Nicola
N
De Stefano
Department of Health Sciences, University of Genoa, Via Balbi 5, 16126 Genoa, Italy. Electronic address: mariapia.sormani@unige.it.
Maria Pia
MP
Sormani
Biomedical Institute at Hasselt University and Rehabilitation & MS-Centre Overpelt, Agoralaan Gebouw A, 3590 Diepenbeek, Belgium. Electronic address: bart.vanwijmeersch@uhasselt.be.
Bart
B
Van Wijmeersch
Department of Neurology, University of Münster, Albert-Schweitzer-Campus 1, Building A10 (previously Domagkstr. 13), 48149 Münster, Germany. Electronic address: heinz.wiendl@ukmuenster.de.
Heinz
H
Wiendl
Department of Neurology, Heinrich-Heine-University, Moorenstrasse 5, 40225 Düsseldorf, Germany. Electronic address: bernd.kieseier@uni-duesseldorf.de.
Bernd C
BC
Kieseier
D003657:Decision Making; D019317:Evidence-Based Medicine; D006801:Humans; D009103:Multiple Sclerosis / Q000188:drug therapy*; D013997:Time Factors; D016896:Treatment Outcome
Breakthrough disease activity; MS therapies; Optimizing treatment; Outcome measures; Switching therapy; Treatment algorithm