Giovannoni Gavin, Turner Benjamin, Gnanapavan Sharmilee, Offiah Curtis, Schmierer Klaus, Marta Monica
Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University London, 4 Newark Street, London E1 2AT, UK; Department of Neurology, Royal London Hospital, Barts Health NHS Trust, London, UK.
Department of Neuroradiology, Royal London Hospital, Barts Health NHS Trust, London, UK.
Mult Scler Relat Disord. 2015 Jul;4(4):329-33. doi: 10.1016/j.msard.2015.04.006. Epub 2015 May 8.
The management of multiple sclerosis is becoming increasingly complex with the emergence of new and more effective disease-modifying therapies (DMT). We propose a new treatment paradigm that individualises treatment based on a choice between two interchangeable therapeutic strategies of maintenance-escalation or induction therapy. We propose treating- to-target of no evident disease activity (NEDA) as defined using clinical and MRI criteria. This algorithm requires active monitoring with a rebaselining MRI, at a point in time after the specific DMT concerned has had sufficient time to work, and at least annual MRI studies to monitor for subclinical relapses. Disease activity on the maintenance-escalation therapy arm of the algorithm indicates a sub-optimal treatment response and should trigger a discussion about switching, or escalating, therapy or the consideration of switching to the induction therapy arm of the algorithm. In comparison, disease activity on an induction therapy arm would be an indication for retreatment or a switch to the maintenance-escalation therapy arm. We envisage the definition of NEDA evolving with time as new technological innovations are adopted into clinical practice, for example the normalisation of whole, or regional, brain atrophy rates and cerebrospinal fluid neurofilament levels.
随着新型且更有效的疾病修正疗法（DMT）的出现，多发性硬化症的管理正变得日益复杂。我们提出一种新的治疗模式，该模式基于维持-升级或诱导治疗这两种可互换的治疗策略之间的选择来实现个体化治疗。我们建议根据临床和MRI标准所定义的无明显疾病活动（NEDA）进行靶向治疗。该算法需要在相关特定DMT有足够时间发挥作用后的某个时间点进行MRI重新基线检查以进行积极监测，并且至少每年进行MRI研究以监测亚临床复发情况。该算法中维持-升级治疗组出现疾病活动表明治疗反应欠佳，应引发关于更换或升级治疗的讨论，或者考虑切换至算法的诱导治疗组。相比之下，诱导治疗组出现疾病活动将提示再次治疗或切换至维持-升级治疗组。我们设想随着新技术创新被应用于临床实践，NEDA的定义会随时间而演变，例如全脑或局部脑萎缩率以及脑脊液神经丝水平的正常化。
