How do doctors decide how to treat a person with multiple sclerosis (MS)?

Choosing a therapy for multiple sclerosis (MS) is often guided by experience (although an appropriate risk/benefit analysis should be undertaken), and subsequently, the response to therapy is assessed. People often have breakthrough disease on the chosen agent, necessitating a treatment change. In fact, every medication switch trial that has ever been done has been positive. Having to switch treatments because of suboptimal response is not only inconvenient, but it also may result in unnecessary loss of brain tissue or irreversible disability. MS clinicians sometimes initially chose a second­line therapy based on certain individuals’ characteristics, including severe, multifocal attack, lack of recovery after an early relapse or a high burden of disease on magnetic resonance imaging (MRI) at diagnosis.

There is some data to suggest that prospective biomarkers will allow doctors to make better treatment decisions by more accurately predicting the appropriate therapy for the appropriate person at the appropriate time. One of the big questions is whether an anti-inflammatory or a neuroprotective agent (or both) is more appropriate. One of the other big pending research questions is whether a combination of two safer drugs will offer the efficacy of one of the more powerful but relatively less safe drugs.