Multiple sclerosis therapeutic strategies: Start safe and effective, reassess early, and escalate if necessary.

M ultiple sclerosis (MS) is a serious disease that, if left untreated, often leads to disability and reduced quality of life. Some of the newer and emerging MS therapies (e.g., natalizumab, fingolimod) hold potential for enhanced efficacy in comparison to more established treatments (i.e., interferon and glatiramer acetate). However, the increased efficacy appears to sometimes come at the costs of safety and monitoring. In assessing the risk/benefit ratio for the individual patient, clinicians must synthesize many factors to decide upon an ideal treatment strategy. Acknowledging that there may be the rare patient with fulminant and rapidly disabling early MS who may need a highly effective treatment at the beginning, agents with considerable safety concerns should generally be used as “second line.” The initiation of a safe and effective first-line agent should include a comprehensive plan for monitoring disease activity, with potential for rapid changes in therapy if necessary.