When and how to start treatment in relapsing MS

WHEN AND HOW TO START TREATMENT IN RELAPSING MS Giancarlo Comi MS Centre Gallarate Hospital, Gallarate, European Charcot Foundation The importance of early treatment is now considered a fundamental step in relapsing multiple sclerosis (RMS). Pathological studies have revealed that acute axonal loss in white and grey matter lesions can be quite large, even in preclinical conditions; these observations have been confirmed by magnetic resonance imaging, evoked potentials and optical coherence tomography. On the other hand, inflammatory activity, the target of disease modifying treatments (DMTs) in RMS, tend to be higher in the initial phases of the disease and decreases with the increase of disease duration. Clinical trials have revealed that DMTs have a stronger efficacy when used in patients with a first attack highly suggestive of MS with a signifcant impact in the risk of accumulating irreversible disability and brain atrophy. Data confirmed by observational studies. The availability of DMTs with different profiles of efficacy and safety allow to select the appropriate treatment for each person with MS according to an accurate estimation of prognostic and predictive factors in combination with the informed preferences expressed by the patient. Recent developments of precision medicine supports the treatment personalisation in order to maximize benefits and minimize risks. Both more recent clinical trials where the new agent was tested against an active comparator, and well performed observational studies suggest that in treatment naif patients starting with a more aggressive treatment produces more short and long term benefits than using an escalating approach.