Dr Patricia Coyle on Escalation vs High-Efficacy Induction in MS

Patricia K. Coyle, MD, of Stony Brook University Neurosciences Institute, explains how studies are trying to answer a debate about 2 approaches to treat multiple sclerosis (MS).


What is the debate about taking an escalation approach versus a high-efficacy induction approach to treat multiple sclerosis?

Induction is a subset of high-efficacy agents that are given for a short period of time and have a long-lasting effect. So I think the first real debate is, would virtually every patient be better off if we treated them with a high-efficacy agent, as opposed to an escalating agent right from the beginning? Currently, we will typically use a high-efficacy agent in patients that we're very worried about, that have aggressive MS that have very active disease that look like they have a bad prognostic profile. Our practice guidelines recommend that, but that's a minority of MS individuals. If you have very mild disease, would you be better off if you were started on a high-efficacy agent that might carry some more risk? Or would you do very well on a very moderately efficacious but quite safe agent? We don't have the answer to that yet. To truly answer that, I think you need randomized prospective studies and there are 2 ongoing, TREAT-MS and DELIVER-MS, that are randomizing patients to a high efficacy or an escalation strategy. And they're going to see which group does better. But there is accumulating data, I think, to say that there are good things that happen when you start with a high-efficacy agent from the beginning.