How Is Multiple Sclerosis Treated?
When James Bowen, M.D., a neurologist in Seattle, began practicing medicine more than 20 years ago, there was not a single approved medication for treating MS. Today, there are 14 that can treat the relapsing-remitting form of the disease, with an additional treatment for relapsing MS and the first ever for primary-progressive MS expected to receive approval this year. “Multiple sclerosis is one of the fastest moving areas of medicine,” says Dr. Bowen.
Even so, MS can be challenging to treat. Depending on the nature of your illness, how severe it is, and your symptoms, your doctor will determine what treatment is best for you. Disease-modifying therapies focus on slowing the progression of the disease and changing the course of MS so you have fewer and less severe attacks. Other medications aim to keep symptoms, such as fatigue, depression, spasticity (muscle stiffness and spasms), and bladder and bowel problems, under control. There are also a few nondrug therapies that can help with some MS symptoms.
Modifying the Disease
Disease-modifying therapies (DMTs) fall into three types: injectable, oral, and those that are administered by intravenous infusion. None of these medications will cure MS—as yet there is no cure—and they don’t prevent symptoms, but they do reduce the accumulation of lesions in the brain and spinal cord and, therefore, the frequency and severity of attacks.
Injectables The injectable DMTs are interferon beta-1a (Avonex, Rebif), interferon beta-1b (Betaseron, Extavia), glatiramer acetate (Copaxone, Glatopa), and peginterferon beta-1a (Plegridy). “The interferons and glatiramer acetate are overall the safest,” says Vijayshree Yadav, M.D., associate professor of neurology at Oregon Health & Science University School of Medicine in Portland, but they are not as effective as some of the newer drugs.
Oral pills Some DMTs—teriflunomide (Aubagio), fingolimod (Gilenya), and dimethyl fumarate (Tecfidera)—are taken orally, in pill form. “Oral agents can lead to liver function problems and lower white blood cell count,” notes Dr. Yadav.
Infusions DMTs that are administered by infusion are alemtuzumab (Lemtrada), mitoxantrone (Novantrone), and natalizumab (Tysabri). Infusion time is typically only about half an hour to an hour, and is repeated from every few days to weeks, depending on your condition and which medicine you are on.
Any of these medications may cause potentially serious side effects, and treatment comes down to a balance between a drug ’s benefits and its risks. Alemtuzumab, for example, can cause some autoimmune diseases, infections, and cancers; in rare cases, natalizumab can trigger a potentially severe brain disease known as progressive multifocal leukoencephalopathy (PML).
“We may choose drugs that have fewer side effects but take longer to begin working in a patient who has a very slowly worsening disease,” says Robert Glenn Smith, M.D., Ph.D., a neurologist at Houston Methodist Hospital in Texas. “Or we may choose a drug that’s a lot more aggressive in its beneficial effects, but may have more side effects, for someone with more active disease.”
With so many treatment options, finding the one that’s right for you may take some trial and error. “It’s very important for patients to work with their doctors to find the right drugs for them,” says Dr. Bowen.
You may need medication to control your symptoms during a severe relapse (also called an exacerbation). “Symptoms such as new loss of vision and weakness and numbness of the arms and legs are the result of inflammation,” explains Dr. Yadav. “A short period—usually three to five days—of high-dose steroids will reduce the inflammation, making the relapse both shorter and less severe. Taking steroids for a long time can cause weight gain, osteoporosis, muscle weakness, and a higher risk of diabetes. Your doctor can suggest other medications that should help with other problems.
MS symptoms can often be lessened without the use of drugs. “Research has shown that if you improve your diet and lose weight if you need to, it can reduce fatigue,” says Dr. Yadav, “and exercise helps with trouble sleeping.” She recommends physical therapy for balance problems, and mindfulness meditation or psychotherapy for depression and anxiety.
On the Horizon
Research on MS has shown promise. Stem cells may be able to slow disease activity and repair damage to the nervous system (called remyelination). In one study, almost 70 percent of patients treated with stem cells were free of neurological symptoms five years later. Several substances, including an antihistamine, show potential for remyelination. A clinical trial of phenytoin, commonly used to prevent seizures in epilepsy, could protect nerves in the eye from damage and also has the potential to slow the progression of disability in MS. While all of these—and many more—are still in trials, researchers hope they’ll be available before too long.