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

In this episode panelists explore "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 ~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 two 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 versus infusion options, and family planning factor into shared decision making for newly diagnosed patients.