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Starting Treatment for MS: Induction vs Escalation

As in other medical conditions, there are two approaches in starting treatment for MS: induction vs escalation. The dilemma has become more evident as the number of available disease-modifying therapies for multiple sclerosis (MS) grows. With induction, the highest efficacy meds are started as the first treatment. The benefit is that halting the disease progress early is believed to change the trajectory of the disease process and ultimately the degree of long-term disability. Large-scale observational studies have demonstrated the high-efficacy early approach to have a greater beneficial impact on patient outcomes. This follows the established guidelines to treat early, as treating earlier has more of an effect than treating later. The downside to this approach is that many of the most effective medications carry with them the greatest risk for adverse events. This is a difficult decision to make as it is conceivable that any individual patient might have responded to a less aggressive approach. With treatment stratification, a low risk and less effective medication is started first. As the disease progresses, therapy is escalated to more effective meds that are known to have greater risks. The trade-off is between increased safety and potential greater long-term disability. The decision is one that should be made by consensus between the patient and her doctor. Currently, there is not sufficient evidence to favor one approach over the other at this time. Fortunately there are two clinical trials underway (DELIVER-MS and TREAT-MS) which are comparing the two approaches through randomization of subjects to receive either standard therapy vs monoclonal antibody infusion or injections.

The most important element of MS treatment is to detect change that will signal when a change in therapy is needed. BeCare MS Link provides an objective measure of neurologic function and disability from home so patients can partner with their doctors in monitoring their disease and guiding their treatment plans.

Reference: Robert A. Bermel. Starting Treatment for MS: Induction vs Escalation – Medscape – May 16, 2022.

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