Are you struggling to make sense of all the medications available for multiple sclerosis (MS)? Wondering what the new MS drug approvals mean for you (spoiler: they could mean something pretty big) if you’ve been on disease-modifying therapy (DMT) for months—even years—already? Not even sure what MS treatments are available?
If there’s an upside to your confusion, it’s that you’re able to ask these questions at all. Twenty years ago, most of these treatments didn’t even exist and the outcome for the disease was poor. “Back before we had DMTs, there were some people who did well, but more often than not, people had progression, and they had a lot of challenges associated with their MS,” says Kathleen Costello, a nurse practitioner and adjunct assistant professor in the Johns Hopkins School of Medicine in Baltimore.
That first DMT, Betaseron (interferon beta-1b), was approved by the U.S. Food and Drug Administration (FDA) in 1993 to inhibit progression of relapsing-remitting MS, the most common form of the disease. More than two decades later, the MS treatment landscape features a robust list of therapies that do everything from minimizing flares to preventing progression. Let’s take a closer look.
What Are You Trying to Treat?
Therapies for MS fall into several categories depending on what aspect of the disease you’re trying to get a handle on. Early on in your diagnosis, your doc may recommend treatment for common MS symptoms like fatigue, balance issues, and difficulty talking. Those therapies might not include drugs at all: Instead you’ll work with a nutritionist, physical therapist, or speech pathologist. Your doctor might also prescribe treatments to specifically address your MS flares—typically, corticosteroids given in a three- to five-day dose.
But the focus of most treatments today is on slowing or even halting progression of the disease itself using DMTs. If you’re a good candidate for DMTs—meaning you have relapsing MS that’s progressing—you might be able to keep the disease at bay for years with medication, especially if you start treatment right away.
“The earlier you start the treatment, the better a patient will do over time,” says Daniel Ontaneda, M.D., a neurologist at Cleveland Clinic’s Mellen Center for Multiple Sclerosis in Ohio. That’s partly because the number of lesions you accumulate during the most inflammatory stage of the disease—which tends to be early on—will determine how severe the secondary progressive phase of the disease is, he explains.
DMT treatment is where things get a little crazy. There are more than 20 different drugs available, with new drug approvals in the works. Some, like Gilenya (fingolimod), Mayzent (siponimod), and Zeposia (ozanimod) are taken orally. Others, like Copaxone (glatiramer acetate) are injected, and still others, including Ocrevus (ocrelizumab) and Tysabri (natalizumab) are received as infusions.
But despite the different ways of taking the meds, they’re all considered DMTs. So, why so many choices?
One Disease, Many Drugs
It turns out, MS has a robust research pipeline, and more medications are being added to the DMT list on a regular basis. The newer drugs are often similar to drugs already on the market, but the ever-evolving world of science means some of the more recent options may have reduced side effects and improved tolerance over older versions. “We’re seeing new medications approved with similar mechanisms of action as we’ve seen before, but perhaps with some refinements to make the medications either more tolerable, easier to use, or more convenient,” says Dr. Ontaneda.
Also, not all DMTs share the same mechanism of action, or way of working. (Sort of like how acetaminophen and ibuprofen both ease your headache but go about it in different ways.) Some DMTs address MS inflammation directly, while others target B-cells, a type of white blood cell implicated in the inflammatory damage that occurs in MS. Blocking them has been shown to be effective in reducing relapses and new MS activity. Other DMTs target different pathways entirely.
The science is ongoing, but right now, experts aren’t sure why some people benefits more from certain types of DMTs than others. Instead, “based on their experience and knowledge of the presentation of MS, physicians work with people to make what they hope to be the best medication decision,” says Costello.
Choosing a Therapy
No one single, codified approach exists to treating MS progression with DMTs, Dr. Ontaneda says. The treatment plan you and your doc decide on will take into account your symptoms, potential side effects, and your personal preference for how the meds are delivered (maybe you don’t mind an injector? Maybe a pill is easier?).
Ultimately, the DMT you take should be something both you and your doctor agree on. That’s not the end of the story, however. You’ll re-visit your DMT decision at regular doctor visits, to determine how well it’s working for you, and if you’ll stay the course on your current DMT or consider switching to another. The two main factors that sway this decision are how you’re tolerating the medication and what your MRI looks like (any new lesions). Your doctor will also be influenced by one of two approaches:
1. Early highly effective treatment. With this approach, your doctor will start you start on the strongest medications right after diagnosis. The idea is to treat the disease early and intensely, to try and halt progression. The medications are highly effective, but the side effects can sometimes be severe.
2. Slowly escalating treatment. This approach advocates beginning patients on a med that isn’t as powerful but has less risks, and then slowly increasing the drug strength over time if needed. “After a person is diagnosed with MS, you start them on their first, moderately effective drug,” explains Dr. Ontaneda. “If they don’t have any new attacks or lesions, you leave them on that medication. If they do, you bump them up to higher efficacy medications.”
The jury is still out of which approach is best (and true to the nature of the disease, one approach may work better for some patients, while the other is preferable to another group). Clinicians at Cleveland Clinic are currently studying these two treatment methods, running a multi-center trial across 24 sites in the U.S. and UK, randomizing patients to an early highly effective treatment approach or an escalation approach.
“We’re going to see how patients do over time,” Dr. Ontaneda says. “It’s not a question of starting treatment early—we know that’s what we have to do. The question is, how intensely should we treat the disease at the outset? And we’re still figuring this part out.”
So where does this leave you? Together with your doctor, talk about the DMTs available to treat your MS, and discuss the approach that you feel makes most sense for you. Don’t be afraid to take an active role in the decision-making process—yes, your doc is the one with the medical knowledge but at the end of the day, it’s your life.