Let's Talk About Multiple Sclerosis Medication
The super-good news? When it comes to drug treatment for multiple sclerosis, you've got serious options, and lots of 'em, too!by Patrick Sullivan Health Writer
Perhaps no area of multiple sclerosis research has generated as much excitement—or hope—as disease-modifying therapies (DMTs) in the last 25 years. Before 1993, treating MS was a matter of reacting to symptoms. That all changed with the U.S. Food and Drug Administration (FDA) approval of Betaseron (interferon 1b), the first DMT approved to treat MS. Now there are more than a dozen. For many people, these medications can do some amazing things, including reduce how fast lesions form and progress in the brain, extend time between relapses, shorten the duration of a relapse, and/or reduce the progression of disability. Not bad, right? Here's everything you need to know about your medication options.
Our Pro Panel
We went to some of the nation’s top MS experts to bring you the most scientific and up-to-date information possible.
Meghan Beier, Ph.D.
Assistant Professor of Physical Medicine and Rehabilitation and Clinical Neuropsychologist
Johns Hopkins Medicine Multiple Sclerosis Center
Bruce Cohen, M.D.
Chief of MS/Neuroimmunology, Department of Neurology
Northwestern University Feinberg School of Medicine
Neeta Garg, M.D.
Associate Professor of Clinical Neurology
University of Miami Miller School of Medicine
DMTs work to reduce the number of lesions and MS relapses, as well as slow the progression of the disease and overall disability.
Self-injections are the way to go if you are risk-adverse. They have 25 years of research behind them, have been shown to be quite effective, and have very few side effects.
The most widely used and effective medication to treat acute relapses are corticosteroids, which are powerful anti-inflammatory medications. Due to the risk of side effects such as osteoporosis, diabetes and joint problems, corticosteroids are a temporary treatment only.
Medications to manage the pain from MS include anticonvulsants, antidepressants, Botox, and cannabinoids.
What Is Multiple Sclerosis (MS), Again?
MS is an inflammatory autoimmune disease that affects your brain, spinal cord, and optic nerves—otherwise known as the central nervous system, or CNS. As you may already know, autoimmune diseases happen when the immune system mistakenly attacks healthy tissue in the body. In MS, the target is myelin, the fatty tissue that protects your nerve cells in the CNS. When myelin is stripped, the signals from the brain can get disrupted and lead to symptoms like numbness, muscle weakness, and blurry vision.
What Are the Medications for MS?
Medications for MS work to reduce and even prevent inflammation from attacking the nerves They include disease-modifying therapies (DMTs), plus a range of other drugs to treat the pain, fatigue, depression, insomnia, and other symptoms that can accompany MS.
As you're developing your treatment plan with your doctor, the first question to ask yourself is: “What’s my risk tolerance?” The answer to that question will often guide your medical team on which drugs to try.
For people who want the lowest risk possible, disease-modifying therapies (DMTs) delivered via self-injection are the way to go. (And don't worry, we're going to break down all the options in a sec.) These drugs have the benefit of being studied and observed since the mid-90s, so they’re known quantities and are well-tolerated, with few side effects.
Another school of thought recommends starting people with MS on the most aggressive drugs—then, dialing back if need be. That usually means going with an infusion drug. Infusions are good for people who value effectiveness and are more willing to take on some risk.
Oral treatments are an option for people who don’t want to inject themselves every day. But because these meds tend to carry the possibility of serious side effects, most medical teams are wary of starting people on them right away. Instead, many doctors prefer to recommend oral medication only if patients don’t do well, or can’t tolerate, other forms of DMT.
Bottom line: DMTs represent a huge step forward in the treatment of multiple sclerosis. Thanks to these medications—and to the other medications that treat the various symptoms of MS—people with MS can enjoy a quality of life unheard of even a generation ago. As more work and funds are poured into refining DMTs, dedicated researchers and physicians march ever closer to a cure for MS. Your job is to stay as healthy and happy as possible until that cure arrives.
In the meantime, let's take a closer look at all of your options.
How Do DMTs Work?
DMTs can prove highly beneficial to people with multiple sclerosis because they curb the faulty inflammatory response that's attacking the nerves' myelin sheath (the process that leads to scarring and formation of lesions, or scleroses). Although it isn't exactly understood how they work, these drugs can interrupt some of the complicated chemical processes that cause inflammation in the first place. And less inflammation means fewer lesions and relapses.
Nearly all of the available DMTs treat only relapsing-remitting MS (RRMS)—the most common form, affecting approximately 85% of patients—and clinically isolated syndrome (CIS), the first flareup of MS-like symptoms that may or may not become MS later.
Many of these drugs are not effective in progressive forms of MS, either secondary-progressive MS (SPMS), which occurs when people with RRMS eventually stop having periods of remission or primary-progressive MS (PPMS), which is a type of MS that progresses from diagnosis with no periods of remission.
The First Wave of DMTs
DMTs for MS belong to a class of medicine called immunomodulators. Before 1993, a way to slow down the progression of multiple sclerosis simply didn’t exist. That all changed with the FDA approval of interferon beta-1b.
The first drugs—Betaseron (interferon beta), Copaxone (glatiramer acetate), and Tysabri (natalizumab)—have now become baselines for testing newer treatments. Many DMTs currently in use have been tested in scientific studies for close to three decades. Studies measured the number of new lesions formed during the study period, the number and rate of MS relapses, and the risk and rate of MS advancing to SPMS. According to a study in Neurology, most people with MS who use DMTs as early as possible see better outcomes than those who allow the disease to run its course.
How Are DMTs Delivered?
Disease-modifying therapies are usually classified by how they’re delivered:
Self-injection daily, weekly, or biweekly
Intravenous infusion a few times a year
Pills once or twice a day
You might not like needles, but if you can tolerate them, these medications have shown through decades of research to be effective at decreasing relapses with few side effects.
Betaseron (interferon beta-1b): This drug shuts down what’s called the inflammation cascade, the chain reaction triggered by the immune system that is at the root of MS. People with MS inject it themselves daily. Side effects are generally mild: irritation at the injection site and, sometimes, an upset stomach.
Avonex (interferon beta-1a): This drug, approved in 1996, is very similar to interferon beta-1b and is believed to work the same way. Avonex was the first therapy approved to treat clinically isolated syndrome (CIS). However, one of the drawbacks of interferon beta-1a is that people may develop antibodies to the drug that can cause it to lose its effectiveness over time.
Plegridy (pegylated interferon beta-1a) was developed to combat the antibody problem, decreasing the chance that antibodies are produced. It requires fewer injections—every other week instead of weekly. Flu-like symptoms and, occasionally, depression are common side effects. Liver disease can also develop and, although rare, it’s recommended you avoid interferons if you’re taking other drugs known to be toxic to the liver.
Copaxone or Glatopa (glatiramer acetate, or GA): GA is a daily injection. Chemically, it looks and acts like one of the proteins that make up the myelin sheath that insulates the neurons. GA has been available since 1996 and is well-tolerated by most people. Side effects are usually limited to irritation around the injection site. Less frequently, it can cause a systemic reaction—a severe allergic reaction with trouble breathing, chest pain, and flu-like symptoms.
Infusions are delivered at your doctor’s office through an I.V. on various schedules. While they require fewer doses than injections, these meds can be very effective at keeping flares at bay, they do carry a higher risk of more serious side effects.
Tysbari (natalizumab): The first infusion drug was approved by the FDA in 2004. Tysabari works by preventing inflammatory proteins from binding to cells. Research shows it can reduce the yearly relapse rate by as much as 54% to 68%, versus an average of 33% for older injectables. You are given an infusion once every four weeks.
Tysbari has a serious drawback: It increases the risk of a potentially disabling or even fatal brain inflammation called progressive multifocal leukoencephalopathy, or PML. PML is triggered by the JC virus, which causes no symptoms and infects 40% to 90% of the general population. JC virus usually lays dormant, but it can be activated in some people who take this drug. Researchers think Tysbari stops certain immune cells—lymphocytes, which normally suppress the JC virus—from crossing the blood-brain barrier, giving the JC virus the opening it needs to attack. Medical teams monitor patients closely for signs of JC virus antibodies, and if they’re found, it’s time to switch to another DMT.
Ocrevus (ocrelizumab): Introduced in 2017, Ocrevus is rapidly becoming the new standard infusion treatment. There is a lower risk of developing PML than from Tysbari. Ocrevus is generally well-tolerated, although people with hepatitis should not take it. People starting this drug get two infusions two weeks apart, and then one every 24 weeks. Currently, Ocrevus is the only DMT approved to treat primary progressive MS.
Rituxan, Ruxience, and Truxima (rituximab): Rituximab is mainly a drug that treats non-Hodgkin’s lymphoma. It’s been repurposed for MS. Rituximab (sold under its various brand names) hasn’t been studied for MS extensively, but what evidence there is suggests it works similarly to Ocrevus. People generally take this medication in a single infusion every 6 to 12 months.
Lemtrada (alemtuzumab): If you don’t benefit after trying two or more other DMTs, your doctor might suggest you try Lemtrada as a treatment of last resort. This drug is given once per day for five days. One year later, you receive it once per day for three days. While the drug can be effective, it does carry a higher risk of serious and sometimes life-threatening side effects than some other MS medications. About 90% of those who take this drug react poorly immediately after the infusion—experiencing nausea, vomiting, and other symptoms—but side effects usually go away within a few hours. About two-thirds of people also develop an infection, such as listeria, herpes, tuberculosis, or hepatitis. Other possible side effects include over- or underactive thyroid, serious blood disorders, gallbladder inflammation, and an increased risk for some cancers.
It's a lot, we know. That's why you'll work closely with your doctor to decide if this treatment makes sense for you.
Oral DMTs have been available for MS since 2010, and they're a great option if you haven't had success with other medications and you prefer as few needles in your life as possible. Oral DMTs include:
Gilyena (fingolimod): Gilenya was the first oral DMT for RRMS. It’s taken once a day. Gilenya keeps inflammation-causing lymphocytes in the lymph nodes, leading to less inflammation in the CNS. It's also the only drug approved to treat pediatric MS. If you have heart issues, your doctor will likely skip this option. The drug can disrupt your normal rhythm.
Teceiferda (dimethyl fumarate): Teceiferda is a twice-a-day medication used in people with RRMS, CIS, and SPMS. One study found that the relapse rate for people taking it is about on par with those taking the older drug Copaxone, which requires a daily shot.
Aubagio (teriflunomide): Aubagio is a once-daily oral medication to treat RRMS. Some research suggests teriflunomide can reduce relapse rate, lesion burden, and disability—but the scientific evidence is limited. This medication may cause birth defects and liver injury.
Mayzent (siponimod): Mayzent is usually a daily oral treatment that works similarly to Gilyena. It has many of the same cardiac side effects and should not be used with people who have had heart trouble in the past.
Mavenclad (cladribine): This is one of the newest MS treatments that was approved by the FDA in March 2019. It’s effective in people with RRMS and may also help people with PPMS. It carries a risk of serious infection and tumor growth, and it’s usually reserved for people who can’t take other forms of DMTs. People usually take this med for up to five consecutive days in two treatment courses, a month apart.
Zeposia (ozanimod): Zeposia just hit the market in June 2020, and it's approved to treat clinically isolated syndrome, RRMS, and active SPMS. Because this drug can slow your heart rate, you'll gradually increase your doses over the first week and then stick to a daily pill after that. It's thought to work by preventing immune cells from entering (and attacking) the central nervous system.
No matter which type of DMT you and your medical team choose, always remember that stopping these medications should always be done under your doctors’ supervision. The American Academy of Neurology (AAN) has created guidelines for stopping DMTs—don’t ever do this on your own, as you may experience serious side effects.
To treat a severe flare, your doctor may also give you a high dose of oral or intravenous corticosteroids. In the short-term, these medications can be quite effective because they repress your immune response, and they do so fairly quickly. Unlike DMTs, though, they don't alter the course of your disease progression. Think of them more like rescue meds.
Corticosteroids can be delivered as pills, shots, inhalers, or topical creams. If you're in need of fast relief, your doctor will usually prescribe a high-dose IV treatment over three to five days, followed by a lower dose pill for an additional one to two weeks. Common steroid meds include:
Prednisone Intensol, Deltasone, or Cordrol (prednisone)
Steroids can trigger a range of side effects when used for longer than a couple months, so your doc will likely limit your steroid scripts to three a year or less. Long-term side effects include:
Stomach pain and indigestion
A metallic taste in your mouth
Mood swings, anxiety, restlessness
Increase heart rate (palpitations)
Swelling of the ankles
Medications to Manage Symptoms
Drugs used to manage MS symptoms are part of a comprehensive MS treatment plan. These medications treat pain, insomnia, spasticity, and more. Of course, treatment for symptoms depends on what your symptoms actually are! Since MS is so individualized with many possible symptoms, we’ll only cover the basics here.
They include medications for:
Studies reveal that people with MS experience higher rates of clinical depression than the general population. Interestingly, they share similar rates to people with other autoimmune conditions such as rheumatoid arthritis (RA) and inflammatory bowel diseases such as ulcerative colitis and Crohn’s, suggesting that inflammation may play a key role.
Aside from psychotherapy, which can be hugely beneficial in just learning how to cope with your condition, medications known as selective serotonin reuptake inhibitors (SSRIs) and selective serotonin-norepinephrine reuptake inhibitors (SSNRIs) are used to treat MS-related depression. These drugs slow down the absorption of neurotransmitters serotonin and norepniephrine—and they help combat depression by improving transmission of signals between neurons.
Antidepressants used to treat MS include:
SSRIs: These are the most widely prescribed antidepressants for people with MS-related depression. If your doctor prescribes an SSRI, it may take several weeks before you notice any improvements. They include:
If you have MS and feel depressed, don’t wait—talk to your doctor. If you need help right now, call the Substance Abuse and Mental Health Services Administration (SAMHSA) hotline at 1-800-662-HELP (4357) for free, confidential, 24/7, 365-day-a-year treatment referral (in English and Spanish) for individuals and families facing mental health crises.
Fatigue in MS is often linked to depression—so your doctor may prescribe any of the antidepressants listed above, including one not listed: The drug Wellbutrin (bupropion) is thought to be one of the most effective of the non-SSRI antidepressants against fatigue, perhaps because it targets the neurotransmitter dopamine.
Other medications to treat MS-related fatigue include:
Non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen or aspirin. One study found that taking 100 mg. of aspirin twice per day significantly reduced MS-related fatigue.
Stimulants: Drugs like Provigil (modafinil) and Nuvigil (armodafinil) promote wakefulness and fight sleepiness. Although nausea, dizziness, anxiety, and irritability are possible side effects of stimulants, people with MS take lower doses than those with other sleep disorders and usually see fewer side effects.
Ritalin (methylphenidate) is another stimulant that is better known as a treatment for attention-deficit hyperactivity disorder (ADHD). Ritalin can help people with MS focus and feel more energized when they’re experiencing fatigue. Ritalin can be habit-forming, though, and can cause nausea and vomiting, irritability, difficulty falling asleep, and mood swings.
Antivirals: Symmetrel (amantadine hydrochloride) is an antiviral medication used to treat flu. It may increase the amount of the neurotransmitter dopamine in the brain, which can help tamp down overactive immune cells that are a hallmark of MS. Dopamine also helps control involuntary movements that come with spasticity.
Pain is quite common in MS; in fact, more than 40% of people with this disease experience some form of it, according to one study. Still, it’s important to understand where your pain is coming from because your doctor may use different methods to treat it depending on the source. There are two main types of pain in MS:
Neurogenic pain, which is a direct result of damage to the CNS
Secondary pain, which is related to spasticity (involuntary contractions of muscles) and/or deconditioning.
Common pain treatments include:
Anticonvulsants: These drugs can help with both types of pain by calming overactive, damaged nerves.
Antidepressants: These drugs do double-duty by treating both depression and chronic pain. That’s because certain antidepressants block the neurotransmitters (serotonin and norepinephrine) that transmit pain signals to the CNS. They include:
Serotonin/norepinephrine reuptake inhibitors (SNRIs):
Botox (botulinim toxin): Botox works by paralyzing muscles, which can stop painful involuntary contractions (spasticity).
Cannabinoids: Research suggests that medical marijuana and medications derived from cannabis are effective at treating pain and spasticity caused by MS. These drugs work by binding to certain receptors on cells and modifying the way pain is perceived.
Spasticity—when muscles in your arms, legs, back or torso clench randomly and involuntarily—is a common symptom of MS. It occurs when the myelin sheaths on the neurons that carry messages to muscles are eaten away by the MS disease process, leading to pain, balance problems, and walking trouble in MS. To treat spasticity, your doctor may prescribe muscle relaxants. They come in pill form or as a surgically implanted pump that delivers the medication directly to the spinal cord.
When nerves that control the bladder, bowels, or pelvic floor become damaged, incontinence—a lack of voluntary control over when you choose to relieve yourself—can occur. When that happens, the bladder sometimes squeezes and forces urine out. Possible medications:
Antispasmadic drugs such as Oxytrol (oxybutinin) may help the bladder relax to produce fewer squeezes.
Botox (botulinim toxin) injections can help block nerve signals to the bladder, which have become erratic due to damage from MS, and improve symptoms.
For bowel incontinence, most healthcare providers recommend lifestyle treatments to keep you “regular,” such as a high-fiber diet, physical activity, and plenty of fluids.
Trouble going to sleep or staying asleep can be caused by depression, medications, chronic pain, and spasticity, all of which should be treated to encourage consistent, quality Zzzs. Healthy sleep hygiene is important, too. If you’re still not getting the sleep you need, talk to your doctor, who might suggest you try:
Melatonin supplements, which are made from a natural hormone in the brain. Levels start to rise after the sun has set, making you sleepy as darkness sets in.
Antihistamines like Benadryl (diphenhydramine HCI), which can make you drowsy.
Sleep medications like Ambien (zolpidem). But do make sure your doctor is aware of all other current medications to avoid a negative interaction.
Treatment for MS: Multiple Sclerosis. “Multiple Sclerosis: Perspectives in Treatment and Pathogenesis.” (2017.) ncbi.nlm.nih.gov/books/NBK470151/
Disease-Modifying Therapies (DMTs) for MS (1.): Agency for Healthcare Research and Quality. (2015.) “Decisional Dilemmas in Discontinuing Prolonged Disease-Modifying Treatment for Multiple Sclerosis.” ncbi.nlm.nih.gov/books/NBK294198/table/introduction.t1/
Disease-Modifying Therapies (DMTs) for MS (2.): UptoDate. (2020.) “Disease-modifying treatment of relapsing-remitting multiple sclerosis in adults.” uptodate.com/contents/disease-modifying-treatment-of-relapsing-remitting-multiple-sclerosis-in-adults
Medications for PPMS (1.): Multiple Sclerosis News Today. (2018.) “Progressive MS Patients with Considerable Disability Ably Treated with Cladribine, UK Case Study Reports.” multiplesclerosisnewstoday.com/2018/07/17/cladribine-effectively-eases-progressive-ms-activity-uk-case-study-reports/
Medications for PPMS (2.): Multiple New England Journal of Medicine. (2017.) “Ocrelizumab versus Placebo in Primary Progressive Multiple Sclerosis” nejm.org/doi/full/10.1056/NEJMoa1606468
Medications for RRMS (1.): Multiple CNS Drugs. (2011.) “Fingolimod: a review of its use in the management of relapsing-remitting multiple sclerosis.” link.springer.com/article/10.2165%2F11207350-000000000-00000
Medications for RRMS (2.): Multiple MedLinePlus. (2019.) “Dimethyl Fumarate.” medlineplus.gov/druginfo/meds/a613028.html
Medications for RRMS (3.): Multiple New England Journal of Medicine. (2011.) “Randomized Trial of Oral Teriflunomide for Relapsing Multiple Sclerosis” nejm.org/doi/10.1056/NEJMoa1014656
Medications for RRMS (4.): Multiple New England Journal of Medicine. (2006.) “A Randomized, Placebo-Controlled Trial of Natalizumab for Relapsing Multiple Sclerosis.” nejm.org/doi/full/10.1056/NEJMoa044397
JC Virus and MS (1.): MS Trust. (2018.) “JC virus and PML.” mstrust.org.uk/a-z/jc-virus-and-pml
JC Virus and MS (2.): Nature Research. (2018.) “The risk of natalizumab-associated PLM is revealed.” nature.com/articles/d42859-018-00025-5
Pain and MS: Neurology. (2004.) “The prevalence of pain in multiple sclerosis.” neurology.org/content/63/5/919.long
Cannabanoids and MS: Current Neurology and Neuroscience Reports. (2017.) “Cannabinoids for Treatment of MS Symptoms: State of the Evidence” link.springer.com/article/10.1007%2Fs11910-018-0859-x