Casanova Bonaventura, Quintanilla-Bordás Carlos, Gascón Francisco
Unitat de Neuroimmunologia, Hospital Universitari i Politècnic La Fe. València, la Universitat de València, 46026 Valencia, Spain.
Unitat de Neuroimmunologia, Hospital Clínic Universitari de València, 46010 Valencia, Spain.
J Pers Med. 2022 Jan 17;12(1):119. doi: 10.3390/jpm12010119.
The treatment strategy of multiple sclerosis (MS) is a highly controversial debate. Currently, there are up to 19 drugs approved. However, there is no clear evidence to guide fundamental decisions such as what treatment should be chosen in first place, when treatment failure or suboptimal response should be considered, or what treatment should be considered in these cases. The "escalation strategy" consists of starting treatment with drugs of low side-effect profile and low efficacy, and "escalating" to drugs of higher efficacy-with more potential side-effects-if necessary. This strategy has prevailed over the years. However, the evidence supporting this strategy is based on short-term studies, in hope that the benefits will stand in the long term. These studies usually do not consider the heterogeneity of the disease and the limited effect that relapses have on the long-term. On the other hand, "early intense therapy" strategy refers to starting treatment with drugs of higher efficacy from the beginning, despite having a less favorable side-effect profile. This approach takes advantage of the so-called "window of opportunity" in hope to maximize the clinical benefits in the long-term. At present, the debate remains open. In this review, we will critically review both strategies. We provide a summary of the current evidence for each strategy without aiming to reach a definite conclusion.
多发性硬化症（MS）的治疗策略是一个极具争议的话题。目前，已有多达19种药物获批。然而，尚无明确证据可指导诸如首先应选择何种治疗、何时应考虑治疗失败或反应欠佳，以及在这些情况下应考虑何种治疗等根本性决策。“逐步升级策略”包括先用副作用小、疗效低的药物开始治疗，如有必要再“升级”至疗效更高但潜在副作用更多的药物。多年来，这一策略一直占据主导地位。然而，支持该策略的证据基于短期研究，寄希望于其益处能长期维持。这些研究通常未考虑疾病的异质性以及复发对长期影响的有限性。另一方面，“早期强化治疗”策略是指从一开始就使用疗效更高的药物进行治疗，尽管其副作用相对较差。这种方法利用了所谓的“机会窗口”，以期长期最大化临床益处。目前，这场争论仍未定论。在本综述中，我们将对这两种策略进行批判性审视。我们对每种策略的现有证据进行了总结，但无意得出明确结论。
