The early initiation of treatment for multiple sclerosis (MS) with high-efficacy disease-modifying therapies (DMTs) may help reduce disability accumulation. However, long-term treatment continuation may become difficult as patients age and develop comorbidities. Research is ongoing to determine when to discontinue DMT in older patients with MS.

There is some evidence suggesting that patients who first receive high-efficacy therapies for their MS may have less disability accumulation compared with those who first receive standard-efficacy therapies. The ongoing, multicenter, randomized controlled DELIVER-MS and TREAT-MS trials comparing first-line therapy consisting of high-efficacy treatments vs standard-efficacy treatments should help provide a definitive answer about whether starting with high-efficacy therapies confers a disability advantage.

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When we initiate a DMT, we generally inform patients that they will be receiving it for at least 2 to 5 years, and most of our patients with MS end up continuing DMTs for 10 or more years. The concept of lifelong therapy is scary to some people, but I think that helping patients understand that MS is a chronic disease will also help them understand the need for long-term therapy. We do hope that if we treat the MS effectively from the start, it might allow a better opportunity for DMT discontinuation later, and treating patients with high-efficacy therapies earlier may be the best way to accomplish this. The immune system becomes somewhat more senescent, so it makes sense that it may be possible to stop DMT at some point.

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The advantages of using highly effective therapies early and consistently may be in balance with the option to then discontinue therapy later in life, when comorbidities become more common. That is, we might think about discontinuing therapy in patients with MS who have been receiving DMT long-term as they get older and develop comorbidities. The logistics of MS treatment, plus other health care issues and, potentially, polypharmacy, may become too much. Adverse events may also become a concern with long-term therapy in patients older than 60 years of age, as they may be more susceptible to infections.

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Defining the point where treatment discontinuation might make sense is likely going to be based on a combination of factors (eg, how long the patient’s MS has been stable, with no new lesion development or relapses; how long they have been receiving DMT; and their age). We are in the process of trying to establish some of these thresholds. So far, some of the best data about treatment discontinuation come from the DISCOMS study, which showed that patients with stable MS who were randomized to discontinue DMT were somewhat more likely to have a recurrence of disease activity based on magnetic resonance imaging. I think that most providers would consider a patient having at least 5 years of stable disease with no new disease activity and being age 60 as a reasonable starting point for considering DMT discontinuation. Many providers are now having conversations about treatment discontinuation and are now switching to a strategy of monitoring patients off therapy in those around 60 years of age, especially if they have had stable MS for many years while receiving DMT and if they are experiencing any adverse effects of their medication.