Medications for Multiple Sclerosis ~ HEALTH- WORLD

The number of drug therapies for multiple sclerosis has increased in the past decade, offering more options — and hope — for people with MS.

A variety of drugs are used to treat multiple sclerosis (MS)and its symptoms. These include so-called disease-modifying drugs, corticosteroids, and other drugs that target specific symptoms and health problems related to MS, such as depression, bladder problems, and digestive issues.

In MS, an abnormal immune response leads to inflammation in the central nervous system, causing damage to the myelin coating that normally protects nerve fibers, and to the nerve fibers themselves. This damage is at the root of the symptoms — which can include blurred or double vision, numbness, tingling, weakness, fatigue, and loss of coordination — experienced by people with MS.

The goal of disease-modifying MS medicines is to stop or slow the damage to the myelin (a process called demyelination) so that flares, or symptom exacerbations, occur less frequently or are less severe. Ideally, MS drugs would also slow or stop the overall progression of the disease; some of the newer drugs have shown promise in this regard. But determining whether a drug can prevent progression over a lifetime requires decades-long studies, and the newer MS drugs have not yet been around for that long.

Even better than stopping a disease is preventing or curing it. In the future, drugs now in very early studies could either reverse the myelin damage or protect against it, according to research published in April 2015 in The Neurologist.

Disease-Modifying MS Medications

Disease-modifying MS drugs work by addressing the inflammatory issues inherent in MS and by changing the way the immune system responds.

“These drugs are all immune modulators,” says James Otis, MD, associate professor of neurology at the Boston University School of Medicine. “They are disease-modifying medications that can change the course of the disease, although they cannot cure it.”

Some are disease-modifying MS drugs taken by injection (administered by either the person with MS or a caregiver); some are pills, taken orally; and some are given by intravenous infusion by a medical professional.

The increasing number of drugs available gives physicians and patients more options — and discussing those options is important.

"Patients need to be involved in picking the drug," Dr. Otis says. "They should ask why a specific drug is recommended, ask about the side effects, and ask to be given a choice.”

One study examining people’s preferences regarding MS treatment, published in March 2015 in the International Journal of MS Care, found that most would strongly prefer a daily oral pill over any type of injection. Participants also rated symptom improvement and prevention of long-term disease progression as more important than preventing relapses when choosing among hypothetical drug options.

The researchers point out, however, that preventing relapses is a proven effect of currently available disease-modifying therapies, while improving symptoms is not.

Cost and insurance coverage are also important considerations to most people when choosing an MS drug treatment. As an article published in Neurology in April 2015 observed, “MS [disease-modifying therapy] costs have accelerated at rates well beyond inflation and substantially above rates observed for drugs in a similar biologic class. There is an urgent need for clinicians, payers, and manufacturers in the United States to confront the soaring costs of DMTs.”

RELATED: The Costs of Multiple Sclerosis Treatment

All of the following disease-modifying drugs are approved by the Food and Drug Administration (FDA) for treatment of relapsing forms of multiple sclerosis, which includes relapsing-remitting MS and secondary-progressive MS with relapses. Only one, Novantrone (mitoxantrone) is specifically approved to treat secondary-progressive MS.

None of these medications are approved by the FDA for use during pregnancy or breastfeeding. Women with MS who are planning a pregnancy should discuss the best treatment approach with their doctor.

No medications have yet been approved for treatment of primary-progressive MS.

Self-Injected Medications

1. Avonex (interferon beta-1a)

Class: Interferon beta
How taken: Once-weekly intramuscular injection
Mechanism: Avonex contains a type of protein, interferon beta, normally produced by the immune system to help fight infection. It is not known how interferon beta-1a treats MS.
Side effects: Flu-like symptoms, low red and white blood cell counts, infections, thyroid problems; rarely, depression or suicidal thoughts, seizures, or liver problems. May worsen existing heart failure.

2. Rebif (interferon beta-1a)

Class: Interferon beta
How taken: Subcutaneous (under the skin) injection taken three times a week
Mechanism: Rebif contains a type of protein, interferon beta, normally produced by the immune system to help fight infection. It is not known how interferon beta-1a treats MS.
Side effects: Flu-like symptoms and injection-site reactions; rarely, suicidal thoughts or depression, liver problems, allergic reactions, seizures, stomach pain.

3. Plegridy (peginterferon beta-1a)

Class: Interferon beta
How taken: Subcutaneous injection taken every two weeks
Mechanism: Plegridy contains a type of protein, interferon beta, normally produced by the immune system to help fight infection. It is not known how interferon beta-1a treats MS.
Side effects: Redness, pain, or swelling at the injection site; flu-like symptoms; depression or suicidal thoughts; allergic reactions; decreased white blood cells or platelets; thyroid problems; and liver problems or worsening of liver problems. May worsen existing heart failure.

4. Betaseron (interferon beta-1b)

Class: Interferon beta
How taken: Subcutaneous injection taken every other day
Mechanism: Betaseron contains a type of protein, interferon beta, normally produced by the immune system to help fight infection. It is not known how interferon beta-1b treats MS.
Side effects: Injection site reactions, flu-like symptoms, low white blood cell counts, headache, rash, stomach pain, weakness; rarely, depression, liver problems, fatigue, yellowing of the eyes, allergic reactions, seizures. May worsen existing heart failure.

5. Extavia (interferon beta-1b)

Class: Interferon beta

How taken: Subcutaneous injection taken every other day
Mechanism: Extavia contains a type of protein, interferon beta, normally produced by the immune system to help fight infection. It is not known how interferon beta-1b treats MS.
Side effects: Injection site reactions, low white blood cell counts, headache, rash, stomach pain, weakness, flu-like symptoms; rarely, depression, liver problems, fatigue, yellowing of the eyes, allergic reactions, seizures. May worsen existing heart failure.

6. Copaxone (glatiramer)

Class: Immunomodulator
How taken: Subcutaneous injection taken once a day or three times a week
Mechanism: Glatiramer appears to block T cells from attacking myelin.
Side effects: Injection-site irritation, flushing, depression, tremors, weakness, weight gain; rarely, hives or a sensation of flushing, chest tightness, and heart palpitations. Copaxone may increase the risk of cancer and serious infections.

7. Glatopa (glatiramer)

Class: Immunomodulator
How taken: Subcutaneous injection taken once a day
Mechanism: Glatopa is a generic version of Copaxone and has the same mechanism.
Side effects: Injection-site irritation, flushing, depression, tremors, weakness, weight gain; rarely, hives or a sensation of flushing, chest tightness, and heart palpitations. Copaxone may increase the risk of cancer and serious infections.

8. Zinbryta (daclizumab)

Class: Monoclonal antibody
How taken: Monthly subcutaneous injection
Mechanism: Zinbryta acts on the immune system in several ways that together result in less MS-related inflammation. But because of the possibility of severe side effects, Zinbryta is recommended primarily for people who have not responded adequately to two or more other MS drugs.
Side effects: Severe liver injury, inflammation of the colon, skin reactions, enlargement of lymph nodes, allergic reaction to the drug, increased risk of infection, and depression. Monthly liver function tests are required for those taking Zinbryta.

Oral Medications

1. Aubagio (teriflunomide)

Class: Pyrimidine synthesis inhibitor
How taken: Once-daily pill
Mechanism: Aubagio stops the division of certain immune cells, reducing the numbers of two types of cells involved in damage to the myelin.
Side effects: High blood pressure, low white blood cell counts, liver damage, nausea, diarrhea, hair loss, arthritis. Women who are pregnant or plan to become pregnant should not take Aubagio; men who plan to have a child should also stop taking this medication.

2. Gilenya (fingolimod)

Class: Sphingosine 1-phosphate receptor modulator
How taken: Once-daily oral capsule
Mechanism: Gilenya works by keeping lymphocytes (white blood cells) in the lymph nodes instead of letting them into the central nervous system. These immune system cells cause the inflammation that is related to MS. If they are kept in the lymph nodes, this inflammation is reduced.
Side effects: Slowed heartbeat, headache, weakness, fatigue, abdominal pain, back pain, depression, vision changes, hair loss, and liver problems. Women who are pregnant or plan to become pregnant should not take this medication.

3. Tecfidera (dimethyl fumarate)

Class: Nrf2 activator
How taken: Oral capsule taken twice a day
Mechanism: It’s not known exactly how Tecfidera works, but it’s thought to inhibit immune cells and to have antioxidant effects.
Side effects: Flushing, nausea, vomiting, diarrhea, low white blood cell count, allergic reactions. Very rare instances of a condition known as progressive multifocal leukoencephalopathy (PML), a disease of the nervous system caused by a virus and seen in people with faulty immune systems, have been reported in Tecfidera users.

Infused Medications

1. Novantrone (mitoxantrone)

Class: Antineoplastic
How taken: Intravenous (IV) infusion given once every three months for two to three years
Mechanism: Novantrone stops immune cells (T cells, B cells, and macrophages) that attack myelin and cause multiple sclerosis.
Side effects: Nausea, hair loss, bladder and other infections, low white blood cell counts, mouth sores, allergic reactions, and cessation of menstrual periods; increased risk of a type of leukemia known as acute myelogenous leukemia; increased risk of colon cancer; lowered resistance to infection. Novantrone may cause serious heart damage. Women who are pregnant, plan to become pregnant, or are breastfeeding should not take Novantrone.

2. Tysabri (natalizumab)

Class: Monoclonal antibody
How taken: IV infusion given once every four weeks
Mechanism: Tysabri prevents immune cells from moving from the bloodstream across the blood–brain barrier into the brain and spinal cord.
Side effects: Headache, fatigue, joint pain, skin rash, diarrhea, injection site reactions, runny nose, sore throat. Using Tysabri increases the risk of a condition known as progressive multifocal leukoencephalopathy (PML).

3. Lemtrada (alemtuzumab)

Class: Monoclonal antibody
How taken: IV infusion administered for five consecutive days initially and for three consecutive days one year later
Mechanism: Lemtrada works by killing certain cells that are involved in the immune system’s attack on myelin. It is not recommended until at least two other MS medication approaches have failed because of the very serious risks associated with taking it.
Side effects: Rash, headache, sleeping problems, joint pain, back pain, diarrhea, stomach pain, flushing. Serious risks include an increased risk of infection; an increased risk for certain cancers, including thyroid cancer, melanoma, and blood cancers; and the risk of developing certain autoimmune problems, possibly leading to abnormal bleeding and/or kidney disease.

Corticosteroids

Corticosteroids, often referred to simply as steroids, include medications such asprednisone and dexamethasone. They are useful in reducing inflammation and calming MS flares, according to the National Multiple Sclerosis Society (NMSS). Possible side effects include stomach upset, insomnia, and high blood sugar — particularly in people with diabetes.

Steroids are best used in the short term. Extended use can lead to other unwanted side effects including mood swings, weight gain, high blood pressure, osteoporosis, glaucoma, cataracts, stomach ulcers, and increased susceptibility to infection. Furthermore, there is no evidence that long-term use of corticosteroids helps reduce symptoms or slows progression of MS, according to the NMSS.

Steroids should not be stopped abruptly, however, because doing so can lead to complications such as extreme tiredness, weakness, and an upset stomach. If you're taking steroids, work with your doctor to gradually taper the dose for optimal safety.

Medications for Symptom Management

In addition to disease-modifying medications and corticosteroids, there is a wide range of other medications available to help manage MS symptoms. According to the National Institute of Neurological Disorders and Stroke, they include:

Antidepressants and anti-anxiety medications, which can be useful in treatingdepression and anxiety but may also help with other MS symptoms, such as pain and muscle spasms
Gastrointestinal medications to help ease nausea, treat ulcers, and remedy constipation
Antibiotics to treat urinary tract (bladder) and other infections
Antispasmodics to ease muscle spasms that can accompany MS

The drug Ampyra (dalfampridine), an oral medication approved to improve walking in adults with MS