Mellen Center for Multiple Sclerosis, Cleveland Clinic, Cleveland, OH, USA.
Division of Psychological Medicine and Clinical Neurosciences, Cardiff University, Cardiff, UK.
Lancet Neurol. 2019 Oct;18(10):973-980. doi: 10.1016/S1474-4422(19)30151-6. Epub 2019 Jul 30.
Treatment decisions in multiple sclerosis are complex given the large number of disease-modifying therapies with diverse safety and efficacy profiles. The importance of early treatment has been recognised but how intensively to treat at onset is not known. Substantial variability exists in treatment selection with weak clinical trial evidence to guide initial treatment choices. Decision-making is made more complicated by variable tolerance for risk of side-effects and inability to accurately predict treatment response. Whether to use moderately effective and safe medications with escalation as needed, or to use higher efficacy medications from the outset, is a key question in clinical practice. Clinical trials in patients with relapsing multiple sclerosis have focused on pairwise comparisons but the effectiveness of different treatment approaches has not been tested. Future pragmatic randomised clinical trials and observational studies will help to inform more rational selection of initial therapies and improve the quality of life of patients with relapsing multiple sclerosis.
由于有许多具有不同安全性和疗效特征的疾病修正治疗方法，多发性硬化症的治疗决策非常复杂。人们已经认识到早期治疗的重要性，但在发病时如何进行强化治疗尚不清楚。治疗选择存在很大的变异性，临床试验证据薄弱，无法指导初始治疗选择。对副作用风险的容忍度不同，以及无法准确预测治疗反应，使得决策变得更加复杂。是使用具有适度疗效和安全性的药物，并根据需要逐步升级，还是从一开始就使用更高疗效的药物，这是临床实践中的一个关键问题。复发型多发性硬化症患者的临床试验主要集中在两两比较上，但不同治疗方法的有效性尚未得到检验。未来的实用随机临床试验和观察性研究将有助于更合理地选择初始治疗方法，并提高复发型多发性硬化症患者的生活质量。
