Treatment options for multiple sclerosis (MS) have increased dramatically since the introduction of the first disease-modifying therapy (DMT), interferon beta-1b, in the early 1990s. While treatment variability remains high, in many industrialized countries, treatment begins after a first episode of MS and often continues indefinitely. Thus, we are now increasingly confronted with aging patients treated for decades with DMT. However, the natural disease course of MS is highly variable and changes with age and disease duration.1 In younger patients, pathology within the central nervous system is dominated by an adaptive immune response. Over time, especially at older ages and with progressive MS, this pathological profile changes to a more compartmentalized inflammation. Clinically, disease activity in younger patients is predominantly that of acute relapses and focal inflammatory changes on magnetic resonance imaging (MRI) scans (ie, new T2 lesions or gadolinium-enhancing lesions) that are caused by this adaptive immune response, whereas many older patients have either developed slowly progressive disability with minimal interruption by acute relapses (and radiological disease activity) or stabilized with neither relapses nor progression.2
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Strijbis EMM, Kerbrat A, Corboy JR. Discontinuation of Disease-Modifying Therapy in Multiple Sclerosis: Should We Stay or Should We Go? JAMA Neurol. Published online April 19, 2021. doi:10.1001/jamaneurol.2021.0764
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