Optimizing treatment outcomes with disease-modifying therapies involves several factors:

• Initiating the appropriate treatment at the appropriate time. Most MS specialists advocate for early intervention, although differences of opinion exist within the MS community:
  • Hawkins, 2012  vs. Amato, 2012
  • Pittock et al., 2006 vs. Frohman et al., 2006

The following image of the natural history of MS indicates the significant amount of MRI activity that occurs in the pre-clinical phase and early relapsing-remitting MS, the gradual decrease in inflammatory attacks (relapses) over time, and the increasing MRI burden of disease that occurs along with a decrease in brain volume. This schematic supports the role of DMTs early in the disease course.

• Explaining to patients and family members about the purpose of disease-modifying therapies in MS management (Rio et al., 2005)
• Setting realistic expectations for the treatment; unrealistic expectations are a common reason why patients discontinue their medication (Mohr et al., 1996).
• Instructing patients on proper use of a medication, particularly injection techniques and rotation regimens to minimize skin reactions with injectable medications (Saunders et al., 2010; Webb, 2008).
• Monitoring for side effects and providing management strategies; inadequate management of side effects is another key reason why people discontinue their medication (Webb, 2008).
• Identifying a sub-optimal response (Cohen et al., 2004; Waubant, 2012)
   
• Treating sub-optimal responders
  • Increasing from a lower dose to a higher dose IFN beta medication (Durelli et al., 2002; Panitch et al., 2002; Schwid & Panitch, 2007) in the absence  of neutralizing antibodies.
  • Switching from an IFN beta medication to glatiramer acetate or vice versa (Freedman et al., 2009; Caon, 2009)
  • Switching from an injectable to fingolimod (Marriott & O’Connor, 2010), which is also considered a first-line option by the FDA
  • Switching from a first-line medication to natalizumab or mitoxantrone (Rudick & Polman, 2009)
  • Combining agents with different mechanisms of action (Rudick & Polman, 2009)

Consensus Criteria for Sub-Optimal Response (Cohen et al., 2004)

• No relapse rate reduction or > 1 relapse/year after 6-12 months of continuous DMT
• Recurrent or new spinal cord or brainstem lesions
• Incomplete recovery from repeated relapses, especially when EDSS score increases
• Progressive cognitive or motor impairment that disrupts ADLs regardless of neurological exam changes (eliminating the influence of medications, depression, or superimposed concurrent illness)
• Polyregional disease development that affects multiple neurologic systems