Induction vs. escalating therapy in multiple sclerosis: practical implications.

Most of the Consensus Groups in Europe and America support an early decision-making therapeutic approach in patients with a diagnosis of Multiple Sclerosis, either with IFNbeta or GA 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, on the reduction of both relapse rate and of the ongoing inflammatory processes. 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, the 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 either Mitoxantrone, Cyclophosphamide, various other immuno-active agents, or the 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 of each single patient. Nevertheless, 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.