Induction versus escalation therapy

Most of the consensus groups in Europe and America support an early decision-making therapeutic approach in patients with a diagnosis of multiple sclerosis (MS), either with interferon-β or glatiramer acetate, which have been demonstrated to be a reasonable therapeutic strategy because of their benefit. The "treat-early approach" within disease management is based on the assumption, particularly during the early phase of the disease, of the reduction of both relapse rate and of the ongoing inflammatory processes may delay irreversible neurological damages. As soon as the MS diagnosis is certain or even in patients with a first episode suggestive of MS, with negative prognostic factors and a typical presentation, "induction therapy", which is more aggressive on the immune system, seems to have more relevant short- and long-lasting beneficial effects. However, if the disease course is suboptimally controlled, an "escalating strategy", using mitoxantrone, cyclophosphamide, various other immunoactive agents or a combination of different drugs, is suggested. The current challenge in therapeutic strategy is to identify the most effective drug, or combination of drugs, during a specific phase of the disease for each single patient. Anyhow, the decision to adopt a combination therapy in patients with a low response to monotherapy should not be delayed until severe irreversible disability is evident.