Substantial progress has been made in risk assessment for patients with myelodysplastic syndromes (MDS). The development of accurate prognostic classification systems allows a risk-adapted treatment strategy in the individual patient. Allogeneic haematopoietic stem cell transplantation (HSCT) was considered until recently as the only curative approach for MDS. Recent data suggest that intensive chemotherapy programs, such as those employed for patients with AML, may lead to prolonged disease-free survival in a low but significant fraction of patients with high-risk MDS. Intensive post-remission chemotherapy, with or without autologous HSCT, may constitute an appropriate alternative for those patients lacking a suitable sibling donor or for older patients who are in remission after intensive chemotherapy. In this review we will summarise the results and future perspectives of intensive chemotherapy for high-risk MDS patients.