If you have been diagnosed with multiple sclerosis (MS) recently, the range of treatments available may look very different from what was on offer in earlier decades. Thirty years ago, neurologists had few options beyond managing symptoms. Today, a group of medicines known as disease-modifying therapies (DMTs) can reduce relapses and slow the progression of MS for many people.
Deciding which treatment to use, and when to start, involves several factors. This article describes how MS treatment has developed over time, what the current options are, and what research has found about the principles now guiding treatment decisions.
Key Takeaways
- How MS treatment has developed over the past three decades
- The difference between moderate-efficacy and high-efficacy DMTs
- What research shows about starting treatment early
- How treatment decisions are made together with your neurologist
- Where current MS research is focused
What Are DMTs?
Disease-modifying therapies are medicines that act on the immune system to reduce the damage MS causes in the brain and spinal cord. They do not cure MS, and they do not reverse damage that has already occurred. Their purpose is to limit further damage.
DMTs are used with three broad aims: to reduce the number of relapses, to reduce the number of new lesions seen on MRI scans, and to slow the long-term accumulation of disability. Research indicates that the effect is greatest when treatment begins early, before substantial damage has built up.
The First Wave: Injectable DMTs (1990s)
Modern MS treatment began in 1993, when the first interferon beta was approved. It was the first medicine shown in trials to reduce relapse rates in MS. Glatiramer acetate was approved a few years later.
These injectable treatments reduced relapses by around one third and could be used over the long term. Common drawbacks included regular injections, skin reactions at the injection site, and flu-like effects. For many people, they were the first treatment option able to alter the course of the disease.
The Second Wave: Oral Medications (2010s)
During the 2010s, the first oral DMTs became available. Fingolimod was approved in 2010, followed by teriflunomide and dimethyl fumarate. These provided alternatives to injections.
Oral medicines made treatment more practical for some people, including those who found regular injections difficult or who lived a long way from clinical support. A more convenient treatment can also support more consistent use, which affects how well a medicine works.
The Third Wave: High-Efficacy Therapies
A further group of treatments, generally more effective than earlier options, became available over time. Natalizumab, given as a monthly infusion, was an early example. A class of medicines known as anti-CD20 therapies; including ocrelizumab and ofatumumab, followed along with cladribine and alemtuzumab.
In clinical trials, these high-efficacy treatments reduced relapse rates by around two thirds or more, compared with around one third for the earlier injectable therapies. They also slowed the accumulation of damage visible on MRI. Increasingly, they are considered as an early option rather than only after other treatments have been tried.
Early Treatment: What the Research Shows
For many years, the usual approach was to begin with a lower-efficacy medicine and move to a stronger one only if needed. This is known as the escalation approach, and it remains appropriate for some people.
Research published over the past decade has compared this with starting a high-efficacy DMT early, an approach sometimes called early intensive treatment. Several studies have found that early use of high-efficacy therapy is associated with slower disability progression, less loss of brain volume, and a lower risk of developing more progressive forms of MS. A common explanation is that damage to the nervous system is difficult to reverse, so the earliest period of treatment may have the most influence on long-term outcomes.
Two Patterns of Progression
Understanding of how MS progresses has developed in recent years. Researchers now describe two separate processes. The first, relapse-associated worsening (RAW), refers to disability that builds up after relapses. The second, progression independent of relapse activity (PIRA), refers to a slower decline that can continue even when no relapses are occurring.
This distinction is relevant to treatment. Current DMTs are effective at reducing relapses, but PIRA remains harder to influence. For this reason, much current research is focused on treatments intended to protect nerve cells and repair myelin, the protective coating around nerves.
De-escalation in Later Life
A further area of research is de-escalation, which is reducing or changing treatment in some circumstances. The immune system tends to become less active with age, which can alter the balance of benefit and risk for stronger DMTs. For some older people with stable MS, reducing or changing treatment may be considered.
Decisions of this kind are made individually with a neurologist, taking into account disease history, MRI stability, age, and general health.
What This Means for You
For people newly diagnosed today, more treatment options and more evidence are available than in the past. The most suitable DMT depends on several factors, including the level of MS activity, other health conditions, pregnancy plans, and personal preferences. These are weighed up together with a neurologist or MS nurse.
For people in regional and rural Australia, many DMTs can be managed through a combination of in-person neurology appointments and telehealth follow-up, which can make ongoing care more accessible at a distance from major centres.
Summary
MS treatment has developed from a small number of injectable medicines with modest effects into a wider range of injectable, oral, and infusion options, several of which are highly effective. Current evidence supports starting treatment early with a medicine matched to a person’s level of disease activity.
Research continues into treatments that may protect nerve cells and repair myelin, rather than only reducing immune activity. For many people, the treatment options available today differ considerably from those available a decade ago.
FAQs
Do I have to stay on a DMT forever? Not necessarily. Treatment is reviewed regularly. Some people switch medications, and some, particularly older adults with stable MS, may eventually reduce or stop treatment under neurology guidance.
Are high-efficacy DMTs safe? All effective medications carry some risk. High-efficacy DMTs are monitored with regular blood tests and MRI scans. Your neurologist weighs the likely benefits against your individual risk profile.
Can I still have children while on a DMT? Many women have healthy pregnancies with MS. Some DMTs need to be paused before pregnancy, and some can be continued. This is planned with your neurologist in advance.
What if my DMT does not seem to be working? Your neurologist monitors this through symptoms, relapses, and MRI scans. If there is breakthrough activity, switching to a more effective DMT is usually the next step considered.
Are DMTs covered by the PBS in Australia? Most approved DMTs are listed on the Pharmaceutical Benefits Scheme (PBS) for people who meet the clinical criteria. Your neurologist or MS nurse can explain what applies to you.
References
- Hauser, S. L., & Cree, B. A. C. (2020). Treatment of multiple sclerosis: A review. The American Journal of Medicine, 133(12), 1380–1390.
- Iaffaldano, P., Lucisano, G., Patti, F., et al. (2021). Early treatment delays long-term disability accrual in RRMS: Results from the BMSD network. Multiple Sclerosis Journal, 27(10), 1543–1555.
- Filippi, M., Amato, M. P., Centonze, D., et al. (2022). Early use of high-efficacy disease-modifying therapies makes the difference in people with multiple sclerosis: An expert opinion. Journal of Neurology, 269(10), 5382–5394.
- Kappos, L., Wolinsky, J. S., Giovannoni, G., et al. (2020). Contribution of relapse-independent progression vs relapse-associated worsening to overall confirmed disability accumulation in typical relapsing MS. JAMA Neurology, 77(9), 1132–1140.
- Vollmer, B. L., Nair, K. V., Sillau, S., et al. (2022). Evolution of disease modifying therapy benefits and risks: An argument for de-escalation as a treatment paradigm for patients with multiple sclerosis. Frontiers in Neurology, 12, 799138.
- Bigaut, K., Collongues, N., & De Seze, J. (2025). Evolution of high-efficacy treatment strategy for relapsing-remitting multiple sclerosis. Multiple Sclerosis and Related Disorders.
