I was recently diagnosed with multiple sclerosis. Are there any new treatments to help me fight this disease?
Answer From Iris Marin Collazo, M.D.
There is no cure for multiple sclerosis (MS), but there has been much progress in developing new drugs to treat it. Research is ongoing to develop new and better disease-modifying therapies (DMTs) for this disease of the central nervous system.
DMTs are designed to reduce the risk of relapses and new MS plaques in the central nervous system. DMTs can also slow the progression of disability and the loss of brain volume mass. The majority of DMTs approved by the Food and Drug Administration (FDA) since the early 1990s are effective at helping to manage relapsing-remitting MS, which affects between 85% and 90% of people diagnosed with this disease.
Some people with relapsing-remitting MS can transition to secondary-progressive MS after several years. Currently available DMTs have little impact on this phase of MS. Therefore, it's best to develop a treatment regimen during the earlier relapsing-remitting phase.
About 10% of people with multiple sclerosis are diagnosed with a progressive form (primary-progressive MS) at the onset of the disease. Currently, there is only one FDA-approved DMT for primary-progressive MS, which has modest effect in slowing the disability accumulation over time.
MS relapses, attacks or exacerbation can be managed with corticosteroids, plasmapheresis or both, which can help with recovery.
Corticosteroids such as intravenous methylprednisolone (Depo-Medrol, Medrol) are medicines that decrease inflammation and have been used to help reduce the symptoms of multiple sclerosis relapses.
Therapeutic plasma exchange (plasmapheresis) is a procedure that involves separating the liquid part of the blood (plasma) from the blood cells. Then the cells are combined with a protein solution (albumin) and put back into the body. This is done to cleanse the liquid portion of the blood, which may contain circulating proteins, and can help with recovery from multiple sclerosis relapses. Possible side effects are dizziness, nausea and a decrease in blood pressure.
- Interferons are medicines that "interfere" with diseases that attack the body. They may work by decreasing inflammation and increasing nerve growth. There are many interferon drugs, and they are given by injection under the skin or in a muscle. There is some controversy about how long interferon helps in the treatment of multiple sclerosis. Possible side effects are reactions where the injection is given, flu-like symptoms, liver irritation and anemia. The dosing of interferon varies depending on which drug is used.
- Glatiramer acetate (Copaxone, Glatopa) can reduce relapse rates in multiple sclerosis and has long-term safety data.
- The monoclonal antibody ofatumumab (Kesimpta, Arzerra), approved by the FDA in 2020, targets cells that damage the nervous system. These cells are called B cells. Ofatumumab, which is given as an injection under the skin, decreases multiple sclerosis brain lesions and worsening symptoms. Possible side effects are infections, local reactions to the injection and headaches.
- Teriflunomide (Aubagio) has convenient once-a-day dosing and affects white blood cells to decrease inflammation.
- Dimethyl fumarate (Tecfidera) decreases inflammation and helps protect cells. Possible side effects are flushing, liver inflammation and digestive tract irritation.
- Fingolimod (Gilenya) was the first FDA-approved oral DMT. It was groundbreaking because of how well it worked and because it could be taken by mouth.
- Siponimod (Mayzent) was approved by the FDA in 2019. This tablet is taken orally and approved for relapsing-remitting and secondary-progressive forms of MS. It's an immune-modulating therapy that helps reduce both relapses and progression of disability.
- Cladribine (Mavenclad) is another oral tablet approved by the FDA in 2019 to treat relapsing-remitting and secondary-progressive forms of MS. In clinical trials, cladribine reduced the progression of disability and significantly reduced relapse rates. Because of safety risks, cladribine is generally used when people cannot take other drugs for MS or when those drugs are not effective.
- Ozanimod (Zeposia) was approved by the FDA in 2020. It decreases the relapse rate of MS. Possible side effects are elevated blood pressure, infections and liver inflammation. The maintenance dose is once a day.
- Monomethyl fumarate (Bafiertam) had a 2020 approval by the FDA and is a time-released medicine. Because the release is slow and steady, researchers hope that side effects will be minimal. Possible side effects are flushing, liver injury, abdominal pain and infections.
- Ponesimod (Ponvory) was approved by the FDA in 2021 and is taken once a day with a gradually increasing dosing schedule. This medicine has a low relapse rate and has demonstrated fewer brain lesions than some other medicines used to treat multiple sclerosis. The possible side effects are respiratory tract infections, high blood pressure, liver irritation, and electrical problems in the heart that affect heart rate and rhythm.
- Ocrelizumab (Ocrevus) was approved by the FDA in 2017. This drug reduces relapse rate and risk of disability progression in relapsing-remitting MS. It is also the first DMT to slow the progression of the primary-progressive form of MS.
- Natalizumab (Tysabri) is a monoclonal antibody that decreases relapse rates and slows the risk of disability.
- Alemtuzumab (Lemtrada, Campath) is a monoclonal antibody that decreases annual relapse rates and demonstrates brain MRI benefits. Possible side effects are thyroid disease and low platelet counts.
Recent developments or emerging therapies
Bruton's tyrosine kinase (BTK) inhibitor is an emerging therapy being studied in relapsing-remitting MS and secondary-progressive MS. It works by predominantly modulating B cells and microglia which are immune cells in the central nervous system.
Stem cell transplantation is a therapy that destroys the immune system of someone with MS and then replaces it with transplanted healthy stem cells. Researchers are still investigating whether this therapy can decrease inflammation in people with MS and help to "reset" the immune system. Possible side effects are fever and infections.
Researchers are learning more about how existing DMTs work to lessen relapses and reduce MS-related lesions in the brain. Further studies will determine whether treatment can delay disability caused by the disease.
More research is needed
Ongoing research shows promise and the benefits, side effects and long-term safety of these new drugs will become clearer with further investigation.
Iris Marin Collazo, M.D.
July 14, 2022
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