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.

Department of Medicine University of British Columbia 2211 Wesbrook Mall Room s199 Vancouver V6T 2B5 Canada

Department of Medicine University of Melbourne 300 Grattan St Melbourne 3050 Australia; Department of Neurology Royal Melbourne Hospital 300 Grattan St Melbourne 3050 Australia

Department of Neurology Center of Clinical Neuroscience 1st Faculty of Medicine General University Hospital Charles University Prague Karlovo namesti 22 Prague 12800 Czech Republic

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