When and How to De-Escalate and Discontinue Multiple Sclerosis Treatments

A recent international workshop reviewed current evidence on multiple sclerosis (MS) treatment de-escalation and discontinuation. The group defined de-escalation as a switch from one disease- modifying therapy (DMT) to a less potent one, decreasing the dose, or extending the dosing interval. They note that aging is associated with immunosenescence (the gradual decline in immune function, which is associated with decreased focal inflammatory activity) and increased risk for opportunistic infections and other safety concerns, such that some MS therapies may no longer have a balanced efficacy-to-safety profile. They discuss several studies that have evaluated disease reactivation in clinically stable patients but may be difficult to generalize…