MS Treatment Strategy: High-Efficacy Therapy vs. Escalation Approach

In this episode, panelists explore the question of "MS Treatment Strategy: High-Efficacy Therapy vs. Escalation Approach." Dr. Williams frames the central question: with earlier MS diagnoses now possible, how has treatment philosophy shifted? The traditional "start low, go slow" escalation model has given way to a high-efficacy-first approach for many clinicians.

Dr. Greenberg explains that high-efficacy therapies are historically defined by annualized relapse rate (ARR) data from clinical trials, with agents achieving an ARR below approximately 0.15-0.2 generally classified as high efficacy. He notes that anti-CD52 agents, anti-CD20 agents, and S1P receptor modulators typically fall in this category, though the classification of individual drugs has evolved as trial populations have changed.

A notable example: teriflunomide, once considered a platform therapy based on older placebo-controlled trials (ARR ~0.33), now demonstrates an ARR of approximately 0.11 in head-to-head trials against BTK inhibitors — blurring the definition of "high efficacy." Dr. Greenberg observes that high-efficacy classification is partly drug- and partly population-dependent.

In his own practice, Dr. Greenberg describes leading with high-efficacy therapies for the majority of patients, citing a dramatic reduction in wheelchair use in his clinic over the past 2 decades as evidence of population-level benefit. He introduces the concept of de-escalation as an area to be addressed later in the discussion.

In the next episode, "Personalizing MS Therapy: Patient Preference and Family Planning Considerations," the panel examines how injection aversion, oral vs. infusion options, and family planning considerations factor into shared decision-making for newly diagnosed patients.