Multiple Sclerosis is a chronic inflammatory condition that attacks the central nervous system. In addition to causing disabilities of the brain and spinal cord, it results in a wide range of symptoms. Controlling the relapse of the condition is an important part of the treatment for multiple sclerosis. Treatment for these symptoms also takes up significant time, space, effort, and resources of the patient. A clear knowledge of when it would be ideal to start, stop, and change the treatment strategies for multiple sclerosis is not common knowledge. The article below answers some questions on the same.

1. When to start?
First-line DMT should begin when the patients get diagnosed with relapsing multiple sclerosis and have already experienced at least one attack in the time period of the past two years. While injectable therapies with glatiramer acetate or high dose of IFNB 1-a are the preferred medications, oral therapies through teriflunomide, dimethyl fumarate, and azathioprine are also known to have similar effects.

DMT-naïve multiple sclerosis patients who have been through two attacks in the previous year and now have an active MRI scan should be provided with a second-line regimen like natalizumab, or fingolimod. If the condition has been aggressive right from the onset, alemtuzumab can be considered to be prescribed.

2. When to change?
Given that a wide range of DMT options is currently available for the treatment of multiple sclerosis patients, any patient with only suboptimal response to current strategies can consider changing to a different plan. In the case of one or more relapses, or incomplete recovery in the previous year where the treatment was with first-line DMT—the treatment can be moved to second-line medication. However, if MRI activity and relapse frequency information doesn’t qualify the use of second-line medication, the patient can shift to a different kind of first-line medication. In the case where the patient suffers from intolerable side effects because of their current medication, they would need to switch to a different DMT in the same line of treatment. Multiple sclerosis patients who have been given natalizumab for the past two years, are anti-JCV antibody-positive, and have been given cytotoxic immunosuppressants, must be moved to a different DMT to avoid the increased risk of Progressive Multifocal Leukoencephalopathy (PML). The wash-out interval must be shortened as much as possible in order to reduce the risk of reactivation of the disease.

3. When to stop?
In the case that a serious adverse reaction is encountered or is likely to happen because of the current drugs being used, the DMT must be stopped. In patients who are about to become pregnant, it is advised that the DMT should be stopped. If the disability progression is confirmed in a patient over the past one year in the absence of relapses and the increase of developments of lesions on MRI, the treatment has to be stopped as that would be a case of progressive multiple sclerosis. DMTs do not work for treating progressive multiple sclerosis. In the case of progressive multiple sclerosis, treatments can be focused on treating the symptoms, physical therapy, disability management, etc.