Should neurologists who treat MS patients be escalators or inducers? Should they start with a moderate efficacy disease-modifying-treatment and switch to a high efficacy drug when patients have a relapse? Even though 70% of the disability in MS accrues from incomplete recovery from relapses? Should they start with the most effective drugs even in patients who do not have poor prognostic factors? Do the benefits of these drugs in preventing permanent disability outweigh the risks? Why are many MS patients willing to take more risks than their treating neurologists? Why are neurologists reluctant to use combinations of drugs as is routinely done in treating rheumatoid arthritis and cancer?

The pendulum is swinging towards aggressive treatment from the start. Older studies of the first- generation MS medications have failed to show a convincing effect on long-term disability. But this is not true for the newer and more effective drugs, which are mainly though not exclusively monoclonal antibodies.

Now a new study, by Harding et al, published in JAMA Neurology, Feb 18, 2019, supports the aggressive approach. Patients who were switched from a moderate to a high efficacy drug did less well than those who were treated aggressively from the start. Those who were not switched after they had “breakthrough disease” did less well than those who were.

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