Emerging disease-modifying therapies in multiple sclerosis.

OPINION STATEMENT: The past two decades have seen tremendous expansion in therapeutic options for multiple sclerosis (MS). While the growing armamentarium of therapies provides physicians and patients an array of available options, it also brings in its wake the challenging responsibility of choosing the optimal therapy for an individual patient. In a newly diagnosed patient with relapsing disease, the current practice is to start one of the interferons (interferon-beta) or glatiramer acetate. With increasing experience and if there are no new safety concerns, use of fingolimod as a first-line agent in relapsing-remitting MS could expand. BG-12 appears to have a safety and efficacy profile that would make it a first-line agent, while tolerability would need to be considered. Teriflunomide is another oral agent that is under review by the US Food and Drug Administration and, apart from the pregnancy concerns, seems a potential first-line choice as well. For patients with high disease activity at onset or those refractory to current first-line agents, natalizumab and fingolimod are the two options considered most often at present. With the potential availability of alemtuzumab in the near future, that will provide an additional option considered highly efficacious. Its efficacy would have to be weighed carefully against its safety profile. Advances in genetics and biomarkers may allow the development of personalized medicine, and thus, the determination of the "best therapy" for an individual patient. Risk stratification strategies such as serum JC virus antibody status and pre-determination an individual's risk of autoimmune disease on alemtuzumab may facilitate early initiation of optimal therapies. Treatments for MS have come a long way and the future looks even more promising and will provide us with better and greater options in treating patients, meaning we can hope to see even less of an impact of the disease in the lives of patients with MS.