Thinking outside the box: non-canonical targets in multiple sclerosis

Multiple sclerosis (MS) is an immune-mediated disease of the central nervous system that causes demyelination, axonal degeneration and astrogliosis, resulting in progressive neurological disability. Fuelled by an evolving understanding of MS immunopathogenesis, the range of available immunotherapies for clinical use has expanded over the past two decades. However, MS remains an incurable disease and even targeted immunotherapies often fail to control insidious disease progression, indicating the need for new and exceptional therapeutic options beyond the established immunological landscape. In this Review, we highlight such non-canonical targets in preclinical MS research with a focus on five highly promising areas: oligodendrocytes; the blood-brain barrier; metabolites and cellular metabolism; the coagulation system; and tolerance induction. Recent findings in these areas may guide the field towards novel targets for future therapeutic approaches in MS. Multiple sclerosis (MS) is an immune-mediated neurological disorder featuring central nervous system demyelination. Increasing understanding of the complex pathophysiology of this disease has led to considerable expansion of the MS therapeutic toolbox over the past 20 years, but substantial limitations remain. In this Review, Sven Meuth and colleagues highlight promising non-classical targets for MS that could provide fruitful avenues for future therapies.