Until recently, the transition to secondary progressive multiple sclerosis (SPMS) meant your treatment options were somewhat limited. Now, new drugs are renewing optimism for people with this form of multiple sclerosis.
As the name implies, SPMS is characterized by progression, rather than relapses and remissions, but the transition from relapsing remitting multiple sclerosis (RRMS) to SPMS is gradual. “There is no one moment when you can say, now you’re in SPMS,” explains Mark Freedman, M.D., director of the Multiple Sclerosis Research Unit of the Ottawa Hospital in Ontario. Even after an SPMS diagnosis, you may continue to have relapses, which can make treatment options both more plentiful and more complicated.
New Treatment Options for Active SPMS
There are two types of SPMS: active and non-active. “When SPMS is active, there is some inflammation,” explains Gloriavon Geldern, M.D., a neurologist at the University of Washington School of Medicine in Seattle. If you have active SPMS, you’re still having relapses. If it’s non-active, your symptoms and functioning may worsen, but you won’t have inflammation or relapses.
With active SPMS, the disease-modifying therapies (DMTs) used to treat RRMS can sometimes still be used, including:
- Aubagio (teriflunomide)
- Avonex, Rebif (interferon beta-1a)
- Betaseron, Extavia (interferon beta-1b)
- Copaxone (glatiramer acetate)
- Gilenya (fingolimod)
- Lemtrada (alemtuzumab)
- Ocrevus (ocrelizumab)
- Plegridy (peginterferon beta-1a)
- Tecfidera (dimethyl fumarate)
- Tysabri (natalizumab)
And now, there are two new options for treating active SPMS. In March 2019, the U.S. Food and Drug Administration (FDA) approved Mavenclad (cladribine) for both active SPMS and RRMS. Taken orally, the drug lowers blood levels of immune cells that attack nerve cells. In April 2019, the FDA approved Mayzent (siponimod) for active SPMS, as well as for RRMS and clinically isolated syndrome. Mayzent is an oral medication that comes in tablet form. It’s an immunomodulating drug that may have anti-inflammatory effects in the brain and spinal cord.
Like other immunosuppressants, both of these newer medications raise your risk for infection. Still, they can be helpful. “It depends on the patient,” says Marwa Kaisey, M.D., a neurologist and MS specialist at Cedars-Sinai Medical Center in Los Angeles. “If MS has progressed to the point where the incidence of infection is high—the person is in a wheelchair, bedridden, or has bladder problems—then immunosuppressants increase infection risk.”
Before starting you on either of these drugs, your doctor will test you for active infection, verify that you’re up-to-date on vaccinations, and evaluate your heart and liver function. For any new treatment you’re considering, whatever the reason, work with your doctor to weigh potential risks and benefits. As Dr. Kaisey says,
“There is no one perfect treatment."
Slowing the Slide of MS Progression
The SPMS drugs work, in part, by cooling inflammation, thus lessening the risk for relapses. They may also slow progression in active SPMS. “I think they’re worth a try with patients in whom we’re not worried about side effects,” says Dr. von Geldern. It’s important to use them early in the course of SPMS, she adds. “Drugs aren’t good at reversing damage; they are designed to prevent further damage. Using them sooner may prevent damage. Using them later may not help.”
It can be hard to tell whether the new drugs are working. “You can switch to new drugs to slow down progression, but it’s difficult to know if they’re having an effect. There still may be decline despite the use of medication, but the decline is slower than it would be without medication,” explains Dr. Freedman. While blood tests and MRIs are not very helpful in gauging the effectiveness of the drugs, clinical measures and evaluation can be.
“You can’t tell quickly [if they’re working] because the illness progresses so slowly,” explains Dr. von Geldern. “For example, we test how long it takes a patient to walk 25 feet. If a year ago it was faster, that shows decline, so we start the drug. If a year from now it’s about the same, that indicates the drug is working. But you also have to do a neurological exam and ask how the person is doing, and base your evaluation on their exam and how they tell you they feel.”
Managing Symptoms of Non-active SPMS
The medications for SPMS are approved only for active SPMS. But there are treatments to improve quality of life and treat troublesome symptoms once you’ve stopped having relapses and are in the non-active stage, says Dr. Kaisey.
Addressing issues such as pain, difficulty sleeping, and emotional ups and downs are all part of treatment for SPMS. Physical therapy can help you stay mobile longer with progressive forms of MS, and cognitive therapies can help keep your mind sharp.
New approaches such as aqua therapy, treatments for sleep apnea and anxiety, and mind-body techniques, such as meditation, can enhance your quality of life with MS.
“We need to have a look at everything,” Dr. von Geldern points out. “Maybe you’re getting worse not because the illness is progressing, but because of pain or not sleeping well. There’s a lot we have to offer from many angles.”
On the medication front, several therapies are currently being tested and may soon offer even more treatment options. “Simvastatin (Zocor, a cholesterol drug) shows promise in decreasing loss of brain volume, and biotin (a B vitamin) in high doses may stabilize disability,” says Dr. Kaisey.