The management of multiple sclerosis is becoming increasingly complex with the emergence of new and more effective disease-modifying therapies (DMT). We propose a new treatment paradigm that individualises treatment based on a choice between two interchangeable therapeutic strategies of maintenance-escalation or induction therapy. We propose treating- to-target of no evident disease activity (NEDA) as defined using clinical and MRI criteria. This algorithm requires active monitoring with a rebaselining MRI, at a point in time after the specific DMT concerned has had sufficient time to work, and at least annual MRI studies to monitor for subclinical relapses. Disease activity on the maintenance-escalation therapy arm of the algorithm indicates a sub-optimal treatment response and should trigger a discussion about switching, or escalating, therapy or the consideration of switching to the induction therapy arm of the algorithm. In comparison, disease activity on an induction therapy arm would be an indication for retreatment or a switch to the maintenance-escalation therapy arm. We envisage the definition of NEDA evolving with time as new technological innovations are adopted into clinical practice, for example the normalisation of whole, or regional, brain atrophy rates and cerebrospinal fluid neurofilament levels.
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At present, NEDA is a composite of three related measures of disease activity: (i) no relapses; (ii) no disability progression and (iii) no MRI activity (new or enlarging T2 lesions or Gd-enhancing lesions, Kwhich in our view represent “subclinical relapses”).
The presence of any of these says your disease is not sufficiently under control. Do something about it,or make sure your neuro does something about this. This is NEDA today.
Dadalti Fragoso Y says “Although reaching NEDA status has become the goal of many trials and papers, not all researchers like this expression. The concept has still to evolve and the expression “no evidence of disease activity” is controversial. Disease activity in MS goes beyond relapses, disability and MRI images”. Why some of us do not like the expression “no evidence of disease activity” (NEDA) in multiple sclerosis. Mult Scler Relat Disord. 2015;4(4):383-4. He says “One major pitfall of the expression NEDA is the fact that there may be evidence that the disease is active in a manner that is not translated into relapses, new lesions on imaging or disability progression” and ” Finally, another negative aspect of the expression NEDA is the false sense of security that it may pass to patients, who might interpret the lack of disease activity as cure”.
However not to aim for NEDA in the first place is surely a lack of ambition in doing your best for the people in your care and it is arrogant to think that people cannot understand that “no evidence of” means that one can not see this undesirable thing but it is not the cure.