Induction and Escalation Therapies in Multiple Sclerosis
Multiple sclerosis (MS) is a chronic demyelinating disease affecting the central nervous system.
Pharmacological therapy of MS includes symptomatic drugs, treatment for relapses (corticosteroid and intravenous
immunoglobulin) and disease modifying drugs (DMDs) defined as pharmacological agents that have
an impact on relapse rate, disability accumulation and radiological outcomes. Two different therapeutic approaches
are widely used in MS: escalation and induction therapy. Escalation therapy consists of an early start
with first line DMDs (beta interferon, glatiramer acetate, teriflunomide, dimethyl fumarate) and if DMDs are
ineffective or partially effective, switching to second line drugs (mitoxantrone, natalizumab, fingolimod). Induction
therapy consists of the early use of immunosuppressant drugs followed by long-term maintenance
treatment, generally with immunomodulatory agents. While the use of natalizumab and fingolimod as first
line drugs is indicated for aggressive forms of MS, the indication for mitoxantrone as an induction treatment
arises from randomized studies demonstrating that induction therapy with mitoxantrone followed by DMD
maintenance is more effective than monotherapy with beta interferon. However, the safety profile of induction
drugs indicates this is not an acceptable therapeutic strategy for all MS patients in all phases of the disease.
The upcoming challenge is to identify patients at high risk of disability development from their clinical
characteristics, radiological findings or biomarkers. Furthermore, future studies to establish an individual
safety profile stratification are needed.
Keywords: Demyelinating disease, disease modifying drugs, escalation therapy, induction therapy, multiple
sclerosis, safety profile.
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