How does progression independent of relapse activity (PIRA) influence your decision to change treatment in relapsing remitting multiple sclerosis?

In a patient who is progressing in the absence of relapse activity, I typically do not change DMT and instead focus on managing the symptoms directly. Such as physical therapy or walking aids, physical worsening, cognitive rehab, OT for fatigue issues, or counseling if mood issues are contributing to progression. However, if there is a clinical trial that is recruiting, I will also offer that as a treatment option.