Rethinking Long-Term Treatment for MS
Over the past few decades, medications that modify the course of multiple sclerosis (called DMTs or disease-modifying therapies) have transformed how we treat this condition. These medications are especially helpful when started early as they reduce relapses and can slow down disability.
But here’s the question many people eventually ask: “Do I have to stay on these medications forever?”
This is exactly what a team of MS experts from around the world discussed at a recent international workshop. They looked at when it might be safe and even helpful to “de-escalate” (step down) or stop DMTs altogether.
Why Consider De-escalation?
There are several reasons to consider scaling back or stopping MS medications, especially as we age or if the disease has been stable for many years:
- The body’s immune system changes with age. As we get older, the immune system naturally becomes less active (a process called immunosenescence), and so MS may also become less inflammatory.
- DMTs may not work as well in older age. Studies show that medications are most effective in younger adults with active MS, but less so in older adults, especially over age 55.
- Medication risks increase over time. Some MS medications can raise the risk of infections, cancers, and complications with other conditions or medications, especially in people with more disability or older age.
- Quality of life matters. Some people grow tired of years of injections, side effects, or frequent hospital visits and are ready for a break.
Who Might Be a Good Candidate for De-escalation?
While decisions are always personal and should be made with your neurologist, research suggests the following groups may consider de-escalation or stopping DMTs:
- Older adults with stable MS (usually age 55–60+) who haven’t had a relapse or new MRI activity in 5+ years.
- People with advanced disability (like needing a wheelchair) and no signs of recent inflammation.
- Patients with health conditions that increase risks of continuing treatment, such as frequent infections or cancer.
- Women who are planning pregnancy, depending on their current treatment and disease activity.
What Are the Risks?
It’s important to remember that stopping or lowering treatment isn’t risk-free. Here’s what studies show:
- Relapse risk tends to be low in stable, older patients but not zero.
- Rebound activity (a flare-up worse than before) is more likely after stopping certain drugs like fingolimod or natalizumab—this needs close supervision and often a planned switch to another therapy.
- Progression of disability may continue even without relapses, so careful monitoring is essential.
Are There Safer Ways to Step Down?
Yes. Here are some safer approaches doctors may use:
- Spacing out infusions: Especially with drugs like ocrelizumab, which may work well even when given less often.
- Switching to a lower-risk DMT: Instead of stopping completely, some patients transition from a high-potency medication to a milder one.
- Using “immune reconstitution therapies”: These are powerful treatments (like cladribine) given for a short time that may offer long-term benefits without ongoing meds.
What Should You Ask Your Doctor?
If you're thinking about reducing or stopping treatment, here are some good starting points:
“How active is my MS right now based on recent MRI scans and symptoms?”
“What are the risks if I stop or switch medications?”
“How will we monitor for changes if I take a break?”
“What are the pros and cons in my specific case?”
Bottom Line
You don’t have to stay on the same MS medication forever but stepping down safely requires planning, shared decision-making, and close follow-up. As always, your MS journey is your own and you're not alone.