A 32-year-old woman with MS (relapsing-remitting) has had 2 relapses in the past year despite being on interferon beta-1a. MRI shows 4 new T2 lesions and 2 gadolinium-enhancing lesions. What is the appropriate escalation strategy?
- A Add glatiramer acetate to interferon beta
- B Switch to a high-efficacy DMT such as natalizumab, ocrelizumab, or alemtuzumab ✓
- C Increase interferon beta dose and add pulse steroids
- D Switch to dimethyl fumarate as next escalation
Correct answer: B. Switch to a high-efficacy DMT such as natalizumab, ocrelizumab, or alemtuzumab
Explanation
Breakthrough disease activity on a first-line DMT (interferon beta, glatiramer acetate) with clinical relapses and active MRI lesions warrants escalation to high-efficacy therapy. Natalizumab, ocrelizumab, ofatumumab, and alemtuzumab are high-efficacy DMTs with superior relapse reduction. Combining two platform therapies is not recommended and does not improve efficacy. Dimethyl fumarate is a moderate-efficacy agent and represents a lateral rather than escalation move. The treatment principle is 'early high-efficacy therapy' in highly active RRMS.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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Written and medically reviewed by the StethoPrep medical team.