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Lancet Neurol. 2019 Jul 30. pii: S1474-4422(19)30151-6. doi: 10.1016/S1474-4422(19)30151-6. [Epub ahead of print]

Early highly effective versus escalation treatment approaches in relapsing multiple sclerosis.

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Mellen Center for Multiple Sclerosis, Cleveland Clinic, Cleveland, OH, USA. Electronic address:
Division of Psychological Medicine and Clinical Neurosciences, Cardiff University, Cardiff, UK.
Clinical Outcomes Research Unit, Department of Medicine, University of Melbourne, Melbourne, VIC, Australia; Department of Neurology, Royal Melbourne Hospital, Melbourne, VIC, Australia.
Mellen Center for Multiple Sclerosis, Cleveland Clinic, Cleveland, OH, USA.
Clinical Neurology, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK.


Treatment decisions in multiple sclerosis are complex given the large number of disease-modifying therapies with diverse safety and efficacy profiles. The importance of early treatment has been recognised but how intensively to treat at onset is not known. Substantial variability exists in treatment selection with weak clinical trial evidence to guide initial treatment choices. Decision-making is made more complicated by variable tolerance for risk of side-effects and inability to accurately predict treatment response. Whether to use moderately effective and safe medications with escalation as needed, or to use higher efficacy medications from the outset, is a key question in clinical practice. Clinical trials in patients with relapsing multiple sclerosis have focused on pairwise comparisons but the effectiveness of different treatment approaches has not been tested. Future pragmatic randomised clinical trials and observational studies will help to inform more rational selection of initial therapies and improve the quality of life of patients with relapsing multiple sclerosis.

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