Initial Treatment for Multiple Sclerosis
Disease-modifying therapies (DMTs) are the first-line treatment for relapsing forms of multiple sclerosis, with interferons beta, glatiramer acetate, and teriflunomide being the most commonly recommended initial options. 1
Classification and Diagnosis
Before initiating treatment, it's important to understand that multiple sclerosis (MS) is classified into four main types:
- Relapsing-remitting MS (RRMS): 85-90% of initial cases
- Secondary progressive MS
- Primary progressive MS
- Benign MS
Diagnosis requires evidence of dissemination in space (multiple lesions in different CNS locations) and clinical symptoms corresponding to these lesions, typically confirmed through:
- MRI imaging
- Cerebrospinal fluid analysis
- Visual evoked potentials
- Comprehensive neurological examination
First-Line Treatment Options
For Relapsing Forms of MS (including clinically isolated syndrome, RRMS, and active secondary progressive disease):
Interferon beta preparations:
- Subcutaneous interferon beta-1b
- Subcutaneous interferon beta-1a
- Intramuscular interferon beta-1a
- Subcutaneous peginterferon beta-1a (requires less frequent administration - once every 2 weeks) 2
Glatiramer acetate:
- Standard dose: 20 mg subcutaneously daily
- High-dose: 40 mg three times weekly (may improve adherence) 3
Teriflunomide
These DMTs reduce annual relapse rates by 29-68% compared to placebo, with early initiation being crucial for reducing neurological damage 1.
Treatment Algorithm Based on Disease Activity
Standard Risk/Mild-Moderate Disease Activity:
- Start with first-line DMTs (interferons, glatiramer acetate, teriflunomide)
- Monitor response with clinical evaluations and annual MRI
- If good response, continue therapy
- If inadequate response or intolerable side effects, switch to another first-line agent or escalate to higher efficacy therapy
High Disease Activity:
- Consider starting with high-efficacy therapies such as natalizumab, ocrelizumab, or ofatumumab 1
- For natalizumab, JCV antibody status must be determined before initiation due to PML risk 4
For Primary Progressive MS:
- Ocrelizumab is the only FDA-approved DMT 1
Acute Relapse Management
For acute relapses, high-dose intravenous methylprednisolone (1g daily for 3 days) is recommended as the first-line treatment, which may be followed by a short course of oral prednisone 1.
Monitoring and Follow-up
- Annual brain MRI is recommended for monitoring disease activity
- Regular clinical evaluation for new neurological symptoms
- JCV antibody testing should be rechecked regularly for patients on natalizumab, as JCV status determines PML risk 1, 4
Common Side Effects and Management
Interferons:
- Flu-like symptoms (most common)
- Injection site reactions
- Patient education and mitigation strategies are key to managing these adverse events and supporting therapy adherence 2
Glatiramer acetate:
- Injection site reactions
- Post-injection systemic reaction (flushing, chest tightness, palpitations)
- Generally favorable side-effect profile, even during long-term use 3
Natalizumab:
Important Considerations
- Early treatment is essential to prevent neurological damage and disability progression
- Treatment should be initiated as soon as the diagnosis is confirmed
- Natalizumab should not be used in combination with immunosuppressants or TNF-α inhibitors 4
- For patients with highly active disease, consider high-efficacy therapies from the outset
- Autologous hematopoietic stem cell transplantation may be considered for treatment-refractory MS with evidence of inflammatory activity 1
By following this treatment approach, patients with MS can experience reduced relapse rates, delayed disability progression, and improved quality of life.