Key Point in Selecting Treatment in MS

Multiple sclerosis (MS) is a demyelinating disease of the central nervous system in which inflammation and degeneration simultaneously from the onset of disease, lead to attacks and progression of disability over time. Regarding to the efficacy and safety of MS drugs in various clinical trials, they are classified into the first line (moderate efficacy) and second or even third line (high efficacy) medication. An important subgroup of patients experience severe nature of disease as highly active MS or treatment failure as breakthrough disease and need to treat with high efficacy disease modifying drugs (DMDs) including natalizumab, alemtuzumab, ocrelizuma, fingolimod and cladribine. We reviewedclinical trials and meta-analyses and expert opinions in the literature for high efficacy DMDs. Although, so far there is no definitive algorithm or established consensus for proper patient selection. The lack of head to head clinical trials and different definitions of treatment failureand highly active disease could explain the absence of treatment guideline in these patients. Disease severity, drug efficacy against the safety, patient’s preference and adherence, monitoring of adverse events, patient age and comorbidities are important points of treatment decisionmaking.