经过20多年对多发性硬化患者推荐逐步治疗策略后，最近出现了对在疾病早期使用高效疗法的相当大兴趣。对于年轻并患有活动性疾病、脊髓和脑磁共振成像上有大量局灶性T2病灶且无不可逆性残疾的复发缓解型多发性硬化患者来说，早期使用诱导高效疾病修饰治疗可能具有最佳的风险利益比。虽然我们还没有治愈性的治疗方法，但至少有七类高效药物可供选择，其中有两种主要策略。第一种策略是使用高效药物（如纳他珠单抗、鞘脂1磷酸受体调节剂或抗CD20药物）来实现持续的免疫抑制，这些药物可以作为许多国家的一线治疗。第二种策略是使用诱导治疗药物之一（短期使用联苯四唑、阿曲库胞苷、克拉布毒素或自体造血干细胞移植），这些药物主要推荐用作患有非常活跃或侵袭性多发性硬化疾病的患者的二线或三线治疗。早期持续的免疫抑制会使患者在累积暴露时间的影响下暴露于感染和癌症风险的增加，而诱导药物则使患者在初始治疗后的一段时间内暴露于类似的风险，尽管这些风险会随时间的推移而减少。现在应该重新评估其初期潜在的安全风险，考虑长期数据和其方案的一些重大变化：纳他珠单抗会进行约翰·坎宁安病毒的长期监测；使用每月一次的联苯四唑疗程，最大累积剂量为36-72 mg/m2，然后改用更安全的疾病修饰药物；克拉布毒素只需每2周进行一次治疗，前两年需要进行系统治疗，之后两年则不需要；阿曲库胞苷的安全性和临床影响已经在最后一次输液之后超过6年得到了记录；自体造血干细胞移植明显降低移植相关的死亡率，采用新的方案和指南。逐步治疗和诱导/高效治疗需要严谨的磁共振成像监测。通过使用MAGNIMS评分或美国神经学学会指南进行多年的监测，可以大大提高预测准确性，并便于选择需要积极治疗的复发缓解型多发性硬化患者。© 2023. 作者。

After more than 2 decades of recommending an escalating strategy for the treatment of most patients with multiple sclerosis, there has recently been considerable interest in the use of high-efficacy therapies in the early stage of the disease. Early intervention with induction/high-efficacy disease-modifying therapy may have the best risk-benefit profile for patients with relapsing-remitting multiple sclerosis who are young and have active disease, numerous focal T2 lesions on spinal and brain magnetic resonance imaging, and no irreversible disability. Although we have no curative treatment, at least seven classes of high-efficacy drugs are available, with two main strategies. The first strategy involves the use of high-efficacy drugs (e.g., natalizumab, sphingosine 1-phosphate receptor modulators, or anti-CD20 drugs) to achieve sustained immunosuppression. These can be used as a first-line therapy in many countries. The second strategy entails the use of one of the induction drugs (short-term use of mitoxantrone, alemtuzumab, cladribine, or autologous hematopoietic stem cell transplant) that are mainly recommended as a second-line or third-line treatment in patients with very active or aggressive multiple sclerosis disease. Early sustained immunosuppression exposes patients to heightened risks of infection and cancer proportionate to cumulative exposure, and induction drugs expose patients to similar risks during the initial post-treatment period, although these risks decrease over time. Their initial potential safety risks should now be revisited, taking account of long-term data and some major changes in their regimens: natalizumab with the long-term monitoring of John Cunningham virus; use of monthly courses of mitoxantrone with maximum cumulative doses of 36-72 mg/m2, followed by a safer disease-modifying drug; cladribine with only 2-weekly treatment courses required in years 1 and 2 and no systematic treatment for the following 2 years; alemtuzumab, whose safety and clinical impacts have now been documented for more than 6 years after the last infusion; and autologous haematopoietic stem cell transplant, which dramatically reduces transplantation-related mortality with a new regimen and guidelines. Escalation and induction/high-efficacy treatments need rigorous magnetic resonance imaging monitoring. Monitoring over the first few years, using the MAGNIMS score or American Academy of Neurology guidelines, considerably improves prediction accuracy and facilitates the selection of patients with relapsing-remitting multiple sclerosis requiring aggressive treatment.© 2023. The Author(s).