What are the initial treatment options for multiple sclerosis?

Initial Treatment Options for Multiple Sclerosis

Disease-modifying therapies (DMTs) of high efficacy should be initiated early in the course of multiple sclerosis to prevent relapses and delay disability progression. 1

Disease Classification and Assessment

• Multiple sclerosis (MS) is classified into relapsing-remitting (EMRR), secondary progressive (EMSP), and primary progressive (EMPP) forms, which determines treatment approach 1
• Initial assessment should include a complete brain MRI with contrast-enhanced T1 and T2/FLAIR sequences to establish baseline lesion load and inflammatory activity 1
• The Expanded Disability Status Scale (EDSS) score is essential for determining treatment eligibility and monitoring disease progression 1

First-Line Treatment Options for Relapsing MS

High-Efficacy Monoclonal Antibodies

• Monoclonal antibodies (alemtuzumab, natalizumab, ocrelizumab, ofatumumab) are recommended as initial therapy, especially for patients with aggressive disease features 1, 2
• Natalizumab is indicated as monotherapy for relapsing forms of MS, including clinically isolated syndrome, relapsing-remitting disease, and active secondary progressive disease 3
• CAUTION: Natalizumab increases risk of progressive multifocal leukoencephalopathy (PML), requiring regular monitoring with MRI every 3-4 months in high-risk patients 1, 3

Traditional Injectable Therapies

• Interferons (IFNβ-1a, IFNβ-1b) and glatiramer acetate have established safety profiles with long-term data 4, 5
• These injectable therapies reduce relapse rates and delay disability progression, making them suitable first-line options despite requiring regular injections 4, 6
• Peginterferon beta-1a requires less frequent administration (once every 2 weeks) compared to other interferons, potentially improving adherence 4

Oral Therapies

• Oral DMTs including fingolimod, teriflunomide, and dimethyl fumarate provide efficacy with the convenience of oral administration 2, 6
• These agents are often considered for patients who prefer oral medication or have difficulty with injections 2

Treatment Strategy Recommendations

• Current evidence favors early intervention with high-efficacy DMTs rather than traditional escalation approaches 1
• For patients with markers of aggressive disease (frequent relapses, incomplete recovery, multiple new MRI lesions), high-efficacy DMTs should be initiated immediately 1
• Disease-modifying therapies should be started early in the disease course before irreversible disability develops 5, 7

Treatment for Progressive Forms of MS

• For primary progressive MS (EMPP), ocrelizumab is specifically indicated to slow disability progression 1
• For secondary progressive MS with active inflammation, several DMTs may be appropriate based on inflammatory activity 1

Advanced Treatment Options for Refractory Disease

• For highly active MS that doesn't respond to high-efficacy DMTs, autologous hematopoietic stem cell transplantation (AHSCT) may be considered 8, 1
• AHSCT is most appropriate for younger patients (<45 years) with shorter disease duration (<10 years) and evidence of inflammatory activity 1
• AHSCT is not recommended for advanced progressive MS without inflammatory activity 1

Monitoring Treatment Response

• Follow-up MRI should be performed at least annually, with more frequent monitoring (every 3-4 months) for patients at high risk of treatment complications 1, 9
• Treatment efficacy should be assessed through clinical evaluation (relapse frequency, disability progression) and MRI monitoring (new/enlarging T2 lesions, gadolinium-enhancing lesions) 1
• Patients receiving natalizumab should be monitored closely with regular MRI scans due to PML risk 1, 3

Treatment Considerations for Special Populations

• For MS patients receiving ocrelizumab, COVID-19 vaccination should be administered 4-6 weeks before starting treatment or 4-6 months after ending treatment 8
• Patients receiving immunoreconstitution therapies (IRT) like alemtuzumab, rituximab, or ocrelizumab should wait 6 months after treatment before receiving vaccinations 8
• Disease-modifying therapies for MS can reduce antibody response to vaccines, requiring careful timing of vaccinations 8

Treatment Discontinuation Considerations

• For patients over 55 years with stable disease, discontinuation of DMTs may be considered as the risks of continued immunosuppression may outweigh benefits 1, 9
• Younger patients (<45 years) with short disease duration or history of highly active disease should generally continue therapy even if currently stable 1, 9