How does your decision to use high-efficacy disease-modifying treatments (HET) differ, if at all, when treating late-onset relapsing-remitting multiple sclerosis?

For late-onset patients who still have evidence of active disease (gad-enhancing lesions on MRI within the past 1-2 years), I will treat with HET, such as anti-CD20 therapy. Older individuals tend to have less ability to fully recover post-relapses than younger persons. I would be more hesitant to use natalizumab unless there was evidence of high disease activity (multiple enhancing lesions or multiple relapses over the preceding year). However, needs to pay more attention to co-morbidities and ...

There is good evidence that patients with late-onset MS (LOMS) have a greater risk for progression/disability. However, since many patients with LOMS have prior disease burden evident on MRI, it remains unclear if the increased progression risk relates to unique phenotypic pathology or rather missed opportunities for early intervention, when DMTs are known to be far more effective.

Given the higher risk for disability in LOMS, high-efficacy DMTs are frequently utilized in this population, though...