Timing of high-efficacy therapy in relapsing-remitting multiple sclerosis: A systematic review

Autoimmun Rev. 2017 Jun;16(6):658-665. doi: 10.1016/j.autrev.2017.04.010. Epub 2017 Apr 17.


Background: Immunotherapy initiated early after first presentation of relapsing-remitting multiple sclerosis is associated with improved long-term outcomes. One can therefore speculate that early initiation of highly effective immunotherapies, with an average efficacy that is superior to the typical first-line therapies, could further improve relapse and disability outcomes. However, the most common treatment strategy is to commence first-line therapies, followed by treatment escalation in patients who continue to experience on-treatment disease activity. While this monitoring approach is logical, the current lack of effective regenerative or remyelinating therapies behoves us to consider high-efficacy treatment strategies from disease onset (including induction therapy) in order to prevent irreversible disability.

Objective: In this systematic review, we evaluate the effect of high-efficacy immunotherapies at different stages of MS.

Methods: A systematic review of literature reporting outcomes of treatment with fingolimod, natalizumab or alemtuzumab at different stages of MS was carried out.

Results and conclusions: Twelve publications reporting relevant information were included in the systematic review. The literature suggests that treatment with high-efficacy immunotherapies is more potent in suppressing relapse activity when initiated early vs. with a delay after the MS diagnosis. The evidence reported for disability and MRI outcomes is inconclusive.

Keywords: Alemtuzumab; Disease modifying therapy; Fingolimod; Natalizumab; Relapsing-remitting multiple sclerosis; Systematic review.

Publication types

  • Review
  • Systematic Review

MeSH terms

  • Alemtuzumab
  • Antibodies, Monoclonal, Humanized / therapeutic use
  • Fingolimod Hydrochloride / therapeutic use
  • Humans
  • Immunosuppressive Agents / therapeutic use*
  • Multiple Sclerosis, Relapsing-Remitting / drug therapy*
  • Natalizumab / therapeutic use
  • Treatment Outcome


  • Antibodies, Monoclonal, Humanized
  • Immunosuppressive Agents
  • Natalizumab
  • Alemtuzumab
  • Fingolimod Hydrochloride