As our knowledge and understanding of the underlying pathogenesis of MS increases, so the treatment arena continues to evolve.
At the recent 38th Congress of ECTRIMS  therapeutic choices, targets and treatment timing were considered across several sessions, with the latest findings discussed extensively over the course of the meeting. Individuals with MS, particularly those with relapsing remitting MS (RRMS) can exhibit poor prognostic factors , including low vitamin D levels, a high relapse rate, the presence of spinal cord lesions and higher Expanded Disability Status Scale Score (EDSS). How best to treat patients  is an ongoing quest, with queries as to the optimal strategy to ensure a truly personalised treatment approach. This is particularly important given the range of options now available for treating MS and the consequent issues around choice of therapy  in specific situations. In this edition of ECTRIMS Insights, we will examine some of the data presented at the 38th Congress of ECTRIMS  and explore the impact of this new knowledge on the treatment arena for MS.
Choosing therapy in MS
Therapeutic decision-making in MS involves balancing safety and efficacy, with the most desirable agent being both highly efficacious and well tolerated. As an increasing number of therapies are approved for the treatment of individuals with MS, the number of agents targeting the same disease pathway also increases. Although the B-cell-depleting agents rituximab, ocrelizumab and ofatumumab all target CD20, they bind to different epitopes on the CD20 molecule, resulting in subtle differences in their mechanisms of action . For individuals with RRMS who may have prognostic factors predictive of poor response to treatment, therapy should target beyond focal inflammation. Many such patients initiate therapy soon after diagnosis, receiving disease-modifying therapies (DMTs) with lower or moderate efficacy . However, the use of more highly effective DMTs as first-line treatment  has been shown to lead to better overall outcomes. This approach has been adopted in treatment guidelines for MS, however, there is an argument that treatment should be considered on a case-by-case basis  according to individual patient prognosis. DMTs can differ markedly in their ability to suppress focal inflammation , given the pathogenetically homogeneous nature of MS, this suggests that there may be a limited role for precision medicine in individuals with MS.
Newer induction therapies can provide good and durable disease control  with fewer side effects. In over 10 years’ follow-up of 100 patients with early RRMS receiving mitoxantrone, few required additional therapy, the annual relapse rate was low and the mean EDSS score remained significantly improved. In individuals with MS shown to be stable on induction therapy, de-escalation of that therapy without impacting efficacy is possible , helping to offset some of the risks associated with immunomodulatory therapies.
As described in the previous issue of ECTRIMS Insights , autologous haematopoietic stem cell transplantation (AHSCT) is now a widely accepted treatment option that is highly effective at preventing disease progression and relapse, in addition to reducing inflammatory responses and associated central nervous system (CNS) lesions, in individuals with MS. Revisiting the findings from the 9th ECTRIMS Focused Workshop , the speakers concluded that AHSCT should be offered to all patients with highly active RRMS who fail DMTs, and should also be considered a clinical option for treatment naïve patients with aggressive MS . Appropriate patient selection and monitoring/management of complications, such as autoimmunity and viral reactivation, were noted as key to the success of this procedure.
Healthcare access around the globe
Disparities such as level of disability, geographic location, socioeconomic status, gender and sexual orientation should not be barriers to high-quality care for individuals with MS . Speakers in Scientific Session 15  of the ECTRIMS Congress programme noted that global demand for healthcare resources is outstripping capacity, but that the development and introduction of digital health technologies in areas such as the Middle East and North Africa should improve access and health. High-quality systems to underpin the care of individuals with MS must continue to evolve to overcome barriers to widespread access to healthcare and to remove current ‒ and prevent future ‒ disparities.
Promoting continued advances in research
ECTRIMS welcomes the continued evolution of the therapeutic arena for individuals with MS and applauds the efforts of the scientific community to constantly improve our understanding of how best to optimise patient care. We remain optimistic that ongoing research will continue to improve our knowledge of how best to treat individuals with all types of MS and how best to provide a personalised approach to care.
ECTRIMS Insights articles are produced with an intent of being a neutral source of information sharing and objective analysis for the MS and neuroscience community. Unless otherwise stated, cited information in our articles does equivocate official endorsement from ECTRIMS.
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