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March 17, 1999

Clinical Crossroads: A 29-Year-Old Man With Multiple Sclerosis—Reply

Author Affiliations

Margaret A.WinkerMD, Deputy EditorIndividualAuthorPhil B.FontanarosaMD, Interim CoeditorIndividualAuthor

JAMA. 1999;281(11):985-987. doi:10-1001/pubs.JAMA-ISSN-0098-7484-281-11-jbk0317

In Reply: The intent of my article was not to minimize the importance of rehabilitation or psychological services, but to stress early proactive therapy with available disease-modifying drugs in light of new insights into MS pathogenesis and development of effective drugs. Drugs that are currently available have been shown to reduce the frequency and severity of clinical relapses, to reduce progressive neurologic disability, and to decrease the number of new brain lesions evident by magnetic resonance imaging. There is a growing consensus that these drugs should be started early in the course of MS, before irreversible disability has occurred. The rationale for early therapy includes the following: (1) the immunologic process leading to tissue injury appears increasingly complex as time passes, and may be more difficult to control with immunomodulatory therapy1,2; (2) recurrent central nervous system inflammation starting at the beginning of the MS disease process probably results in irreversible axonal injury at each inflammatory focus3 (the overall amount of damaged central nervous system tissue accumulates during the relapsing-remitting stage of MS); and (3) there is now conclusive evidence that the MS disease process is active in many patients with relapsing-remitting MS during periods of clinical remission.4,5

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