The management of multiple sclerosis (MS) is changing at a rapid rate, with the emergence of a host of new therapeutic interventions in various stages of development. Despite the enthusiasm with which the pharmaceutical industry is hailing these interventions, there remains a need for people involved in the management of MS to be circumspect regarding the true evidence base behind these treatments, particularly when considering prevention of sustained disability and the meaning of change to individuals with MS. MS remains a fundamentally unpredictable condition, which should be managed in the context of an experienced multidisciplinary team. Whilst it may be possible to “personalize” treatment in the future, especially if we can learn more from pharmacogenomics and genome screens, issues of balancing risk against potential benefit of drugs for individual patients are difficult to deal with. The goals of preventing progress from early MS to secondary progression, and making any impact on progressive disease, remain elusive.