An update on the evaluation of treatment switching criteria in multiple sclerosis.

Introduction: Multiple sclerosis (MS) is a complex disorder driven by both inflammatory and neurodegenerative processes. While disease-modifying therapies (DMTs) have significantly improved prognosis, robust treatment switching criteria remain essential to balance efficacy and safety over the disease course.

Areas covered: This review examines historical and current criteria for escalating DMTs from moderate- to high-efficacy therapies (HET). The authors summarize emerging clinical, imaging, and biological markers that inform decision-making and explore strategies for de-escalation, including DMT discontinuation and innovative approaches such as exit and bridge therapies.

Expert opinion: Recent advances in MS management emphasize earlier initiation of HET and more stringent switching criteria. Although innovative monitoring tools - including clinical evaluations, imaging, biological markers, and patient-reported outcomes (PROs) - enhance disease assessment, they require further validation, standardization, and broader accessibility. Similarly, de-escalation criteria need additional research to optimize patient selection.