Abstract
The artificial distinction between relapsing remitting multiple sclerosis (RRMS) and secondary progressive multiple sclerosis (SPMS) can lead to substantial difficulties in decisions on disease-modifying therapy (DMT) at this stage of multiple sclerosis (MS). There is not a simple transition between the two; patients may demonstrate background progression with superimposed relapses for many years. Progressive disease almost certainly starts some years before clinical acknowledgement; once it is identified, clinicians face a dilemma about the use of highly effective DMT. The influence of highly effective therapy on relapses and medium-term outcomes in early disease is well established; however, disentangling efficacy in terms of relapses and progression at this later stage is more complex.
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