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Abstract
Treatment decisions in multiple sclerosis are complex given the large number of disease-modifying
therapies with diverse safety and efficacy profiles. The importance of early treatment
has been recognised but how intensively to treat at onset is not known. Substantial
variability exists in treatment selection with weak clinical trial evidence to guide
initial treatment choices. Decision-making is made more complicated by variable tolerance
for risk of side-effects and inability to accurately predict treatment response. Whether
to use moderately effective and safe medications with escalation as needed, or to
use higher efficacy medications from the outset, is a key question in clinical practice.
Clinical trials in patients with relapsing multiple sclerosis have focused on pairwise
comparisons but the effectiveness of different treatment approaches has not been tested.
Future pragmatic randomised clinical trials and observational studies will help to
inform more rational selection of initial therapies and improve the quality of life
of patients with relapsing multiple sclerosis.