At present there is no cure for MS, but management of the disease includes drug treatments to treat acute inflammatory attacks (or relapses), medications that reduce the risk of further inflammatory relapses (disease modifying therapies) and treatments to slow disease progression. Then there are also therapies that alleviate and improve various symptoms. Successful management of MS also includes a healthy diet, exercise and rehabilitation.
The following information should not be relied on to suggest a course of treatment for a particular individual, and it should not be used in place of a visit, call, consultation or the advice of a physician or other qualified healthcare provider.
Treatment during a relapse
MS relapses are caused by inflammation in the central nervous system that damages the myelin coating around nerve fibres. This damage slows or disrupts the transmission of nerve impulses and causes the symptoms of MS.
Acute relapses are commonly treated with steroids, which can be given intravenously or orally for only a few days. Methylprednisolone is the steroid most often used; prednisone is another commonly used steroid.
The steroids work by damping down the inflammation that is causing demyelination. Steroids are not believed to have any long-term benefit on the course of disease, but they can be effective at:
- reducing inflammation
- shortening the duration of a relapse
- speeding up recovery from a relapse
Steroids do not affect the outcome of a relapse, such as any difficulty or disability that someone might experience following a relapse.
Relapses that don’t respond to steroid treatment, or when steroids should be avoided (such as early-stage pregnancy) can also be treated by intravenous immunoglobulin (IVIG). Plasmapheresis is another type of treatment for steroid-resistant relapses.
Disease modifying treatments are not a cure for MS but aim to prevent or reduce the number of relapses that occur in relapsing-remitting MS.
Drugs commonly used to modify the disease course in relapsing MS
- beta interferon-1a (Avonex): injected into a muscle once a week.
- beta interferon-1a (Rebif): injected under the skin three times a week.
- beta interferon-1b (Betaferon): injected under the skin every other day.
- beta interferon-1b (Extavia): injected under the skin every other day.
- glatiramer acetate (Copaxone or Brabio): injected under the skin daily, or three times a week at a higher dose.
- glatiramer acetate (generic): injected under the skin daily.
- ofatumumab (Kesimpta): injected under the skin once every four weeks.
- peginterferon beta 1a (Plegridy): injected under the skin once every two weeks.
- cladribine (Mavenclad): pills taken for up to five consecutive days in the first month and for up to five consecutive days in the second month, with the same course repeated a year later. This may need to be repeated at some point in the future.
- dimethyl fumarate (Tecfidera): taken as a capsule, twice daily.
- diroximel fumarate (Vumerity): taken as a capsule, twice daily.
- monomethl fumarate (Bafiertam): taken as a capsule, twice daily.
- fingolimod (Gilenya): taken as a capsule, once daily. The first dose is taken under medical supervision to monitor heart rate and blood pressure.
- siponimod (Mayzent): approved to treat relapsing forms of MS and clinically isolated syndrome. It is taken as a tablet, once a day.
- ozanimod (Zeposia): taken as a tablet, once daily.
- ponesimod (Ponvory): taken as a tablet, once daily.
- teriflunomide (Aubagio): taken as a tablet, once daily.
- alemtuzumab (Lemtrada): taken as two treatment courses of intravenous infusions (IV or ‘drip’). The first course consists of intravenous infusions on five consecutive days. The second course is taken 12 months later and consists of intravenous infusions on three consecutive days. Some people may need a third or further infusion.
- ocrelizumab (Ocrevus): taken as an intravenous infusion, with a more intense course to start and then further infusions every six months.
- natalizumab (Tysabri): taken as an intravenous infusion via a drip once every four weeks. It is generally administered in a hospital infusion clinic by a qualified health professional.
Drugs used to modify the disease course in progressive MS
So far, only a few drugs have been approved specifically to treat progressive MS. In some countries, people with relapsing forms of MS who are initially treated with one of the above drugs and are subsequently diagnosed with secondary progressive MS, can continue with their existing treatment if they still experience relapses (a phase described as active secondary progressive MS). In other countries, however, being diagnosed with secondary progressive MS can act as a trigger to stop the individual from being prescribed with drugs approved for relapsing MS.
- ocrelizumab (Ocrevus): approved to treat primary progressive MS. Ocrelizumab is also an immune suppressing or modifying drug. In primary progressive MS it targets B cells. As above, it is taken as an intravenous infusion, with two half doses in the first month followed by further infusions every six months. In some countries (notably those in Europe) there is a more restrictive license that requires people with primary progressive MS to also have evidence of inflammatory activity. This evidence is collected through MRI scans.
- siponimod (Mayzent): approved to treat active secondary progressive MS. As with the treatments above, siponimod is also an immune modifying drug, similar to fingolimod, but with further biological effects. It is taken as a tablet, once a day.
- cladribine (Mavenclad): approved to treat relapsing forms of MS including active/highly active secondary progressive MS. Cladribine is taken as a tablet in two treatment courses, twelve months apart.
- diroximel fumarate (Vumerity): approved by the Food and Drug Administration in the US to treat active secondary progressive MS. It is taken as a capsule, twice daily.
Other drugs that have been used to modify the disease course in MS
In some countries, a number of other immune suppressing or modifying treatments are still used to treat relapsing multiple sclerosis, although in many countries these have been replaced by the treatments above.
They can be useful for some people with MS, such as for those with more severe or frequent relapses or for people whose MS is rapidly worsening. Neurologists and people with MS need to work together to balance the positive effects of the drugs against their potential adverse side effects. These drugs include:
- azathioprine (Imuran)
- cyclophosphamide (Endoxana)
- intravenous immunoglobulin (IVIg)
- methotrexate (Maxtrex)
- mitoxantrone (Novantrone)
- autologous haematopoietic stem cell transplantation (aHSCT): This is usually a disease modifying drug treatment the transplantation of haematopoietic stem cells. It is typically available through clinical trials or as experimental medicine.
Treating MS symptoms
People with MS experience a wide range of symptoms caused by damage to their central nervous system. A number of treatments have been tested for MS symptoms and there has been some progress for particular symptoms such as spasticity and gait problems. However, testing of treatments for use in other symptoms such as fatigue and cognitive impairment has been unclear to date.
Balancing treatment benefits with the risk of side effects is difficult in symptom management. For example, a treatment that improves spasticity and pain but worsens mobility may not be worth pursuing. Neurologists need to work closely with each person with MS to find appropriate treatments for that person’s symptoms. Other symptom management techniques such as rehabilitation, energy conservation and exercise also need to be considered.