The management of relapsing multiple sclerosis (RMS) has been traditionally based on the escalation approach, where initiation of disease-modifying therapy (DMT) with a platform/or first-line agent is followed by prescription of a high-efficacy DMT if an unacceptable level of MS disease activity (relapses) persists [1]. This approach has been challenged in recent years by the observation that damage to the central nervous system (CNS) that leads to long-term disability begins early in the pathogenesis or MS and occurs mostly independently of clinical relapses [2], [3], [4], [5], [6], [7].

These observations have focussed attention on the potential for long-term improvements in clinical outcome from early initiation of a high-efficacy DMT for a patient with active RMS [8]. More clinical data on this approach is required, and MS registries provide an opportunity to evaluate the effects of DMTs in specified subpopulations of MS patients. We have analysed data from the national MS register of Kuwait to evaluate the efficacy of three high-efficacy DMTs (cladribine tablets, alemtuzumab and ocrelizumab) prescribed as initial pharmacologic DMT for patients with RMS in a real-world clinical setting.