Abstract
The scenario of multiple sclerosis (MS) treatment has changed profoundly in recent decades. In this setting, one of two strategies is usually used: escalation or induction. The first involves a pyramid of possible treatments of increasing efficacy (but also increasing safety risks) that are introduced progressively as needed. The induction strategy, on the other hand, immediately pursues higher efficacy, since drugs with a higher risk profile are used from the outset. Understanding which of these treatment strategies is the more suitable for a given patient is the first step in the therapeutic decision-making process. Prognostic factors evaluated on the basis of the clinical presentation and any disease activity on magnetic resonance imaging (MRI) should guide and help clinicians in making their choices.Even though the pathogenesis of MS is not yet completely understood, specific pathological changes are known to occur in the adaptive and innate immune system over the course of the disease. To date, treatment has been based mainly on two drugs, mitoxantrone and cyclophosphamide, autologous haematopoietic stem cell therapy (within clinical trial setting), but new compounds are now emerging. Among the new treatments, alemtuzumab and cladribine appear to be valid candidates as induction drugs.In this review we provide an overview of induction strategies based on literature evidence and our own past experiences, providing descriptions of clinical cases. We also outline the future perspectives in this field.
Highlights
Multiple sclerosis (MS) is a progressive and highly debilitating disease that places a high burden both on individual patients and on society
Two strategies for managing MS therapies have been recognized: escalation (Fig. 1a), where treatment starts with lower-risk, lower-efficacy disease-modifying therapies (DMTs) and only moves on to more aggressive treatments if the ongoing approach fails; and induction (Fig. 1b), which can be defined as treatment based on the use of high-efficacy DMTs with a sustained, long-term biological effect in treatment-naïve patients
The range of possible treatments for MS has undergone a rapid expansion in recent years, and while this development certainly represents an enormous resource, on the other hand it presents every MS specialist with major challenges
Summary
Multiple sclerosis (MS) is a progressive and highly debilitating disease that places a high burden both on individual patients and on society. Since in our treatment landscape we still do not have drugs able to modify the neurodegenerative component of disease, one would want to time treatment to coincide with the presence of ongoing inflammation This concept has been defined has “treatment window” [9] in which we can detect the early opportunity to influence the accumulation of irreversible long-term damage, choosing high-efficacy therapy that targets both focal and diffuse pathology having a favorable impact on long-term outcomes [10]. In view of evidence that high-efficacy therapies carry greater safety risks, the induction strategy has generally been reserved for patients whose disease is very active and aggressive in terms of clinical relapses or disease activity on magnetic resonance imaging (MRI) Patients falling into this category are defined “highly active”, a label that indicates the presence of very active and aggressive disease at the time of observation, but may indicate the presence of concomitant negative prognostic factors.
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