A suggested treatment algorithm is outlined in Figure 1.1 Patients with mildly or moderately active MS should be initiated on a first-line agent and an escalation strategy should be used. For patients with highly active disease or an aggressive form of MS, highly effective therapies are considered first-line upfront. Unfortunately, there is no definitive way to determine a patient’s disease severity, however various patient or disease characteristics have been associated with poorer outcomes and often justify more aggressive therapy. Factors that may indicate the use of more aggressive therapy are shown in Table 2.   

To ensure treatment success, monitoring of compliance, safety, tolerability, and efficacy is essential.1 Due to the absence of biomarkers in MS, efficacy is often measured by the course of the disease after initiating treatment and determining whether the disease is considered to be “active” or “progressive”. MS is considered “active” when clinical relapses or MRI activity is observed or “progressive” when clinical evaluation determines neurological disability has increased.

Switching DMTs may be necessary due to various factors, including treatment failure.1 For patients who require a medication change due to an intolerance or compliance issues, switching to another first-line agent with a different mechanism of action is reasonable. Although switching from a first-line agent to a higher efficacy medication has been found to reduce relapse rates in observational studies, the authors state it is truly important to reassess whether a patient meets the criteria for aggressive or highly active disease prior to initiating a higher efficacy medication. It is important to note that when switching therapy, washout periods are recommended to avoid drug toxicity and immunosuppression.

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MS is a debilitating disease that greatly decreases a patient’s quality of life. DMTs have proven efficacy in patients with relapsing MS by reducing relapse rates, accumulation of disease burden, and decline in neurological function. It is suggested that treatment of MS should be highly individualized and that all patient factors should be considered prior to initiating therapy.


1.      Wingerchuk DM, Weinshenker BG. Disease modifying therapies for relapsing multiple sclerosis. BMJ. 2016 Aug 22; 354. DOI: http://dx.doi.org/10.1136/ bmj.i3518.