Multiple sclerosis (MS) is a chronic inflammatory central nervous system disease that causes often disabling physical symptoms, including problems with mobility, vision, coordination and cognitive function, as well as fatigue and pain.
If you've been diagnosed with relapsing-remitting MS, your doctor is likely to recommend immediate treatment with medications known as disease-modifying therapy (DMT). DMTs have been shown to reduce the number of MS relapses and delay progression of disability to some degree.
These drugs differ in how they're taken and how often, whether they can be taken during pregnancy, and what side effects they can cause. They also differ in how people respond to them, and a person's response to a drug can change over time. Also, DMTs aren't a cure, and you might still need treatment for symptoms of MS.
An understanding of DMTs can help you and your doctor form the best treatment strategy for your relapsing-remitting MS.
Interferon beta drugs. These medications are among the first DMTs approved for relapsing MS and are still used as first line therapy. They include:
- Avonex (interferon beta-1a)
- Betaseron (interferon beta-1b)
- Extavia (interferon beta-1b)
- Rebif (interferon beta-1a)
- Plegridy (peginterferon beta-1a)
The interferon beta medications are given by self-injection, either under the skin or in a muscle. The frequency of injections varies from once every two days to once every two weeks.
These drugs have moderate to strong evidence of effectiveness, reducing the relapse rate and slowing the development of new MS-related brain lesions for relapsing MS.
These drugs are considered generally safe and require minimal monitoring. Flu-like symptoms and injection site reactions, such as redness and discomfort, are commonly reported side effects of interferon beta drugs.
Glatiramer acetate (Copaxone, Glatopa). This also is considered an initial therapy option for relapsing MS. This drug is thought to act through immune system cells known as T cells. It might also have nerve-protecting effects.
Glatiramer acetate is given by self-injection under the skin, either three times weekly or every day. It's generally well tolerated, but injection site reactions, such as redness and discomfort, are common.
Ocrelizumab (Ocrevus). This is the first drug approved by the Food and Drug Administration (FDA) to treat both relapsing MS and primary-progressive MS. Not only has it been shown to reduce relapses, but it can slow disease progression.
Ocrelizumab is given as an IV infusion initially twice in two weeks. After that, the infusion is given every six months. Infusion reactions, such as a headache, rash, nausea and fever, are common. Your doctor might recommend that you be given a corticosteroid and an antihistamine before infusion to help prevent reactions.
People with hepatitis B shouldn't take ocrelizamab.
Natalizumab (Tysabri) is a humanized monoclonal antibody that reduces the migration of immune cells across the blood-brain barrier into the central nervous system. This medication is given intravenously every four weeks.
Natalizumab is effective against relapsing MS, reducing the relapse rate by about two-thirds. However, it's associated with a small but important risk of a serious brain infection known as progressive multifocal leukoencephalopathy (PML).
People who take natalizumab must be closely monitored for symptoms of PML, which include progressive weakness and visual or cognitive changes that might not be reversible.
A person's ongoing PML risk is assessed using factors such as:
- The presence of antibodies to a virus known as John Cunningham virus on blood testing
- Previous treatment of immunosuppressive drugs, such as mitoxantrone
- Taking natalizumab longer than two years
Alemtuzumab (Lemtrada). This drug helps reduce relapses of MS by targeting a protein on the surface of immune cells and depleting white blood cells. This effect can limit potential nerve damage caused by the white blood cells, but it also increases the risk of infections and autoimmune disorders.
Treatment with alemtuzumab involves five consecutive days of drug infusions followed by three days of infusions a year later. Infusion reactions, such as a headache, rash, nausea and fever, are common with alemtuzumab.
Due to the risks associated with alemtuzamab, the FDA recommends extensive screening before using the drug. It's only available from registered providers, and people treated with alemtuzumab must be registered in a special drug safety monitoring program.
These oral DMTs are approved for treating relapsing MS.
Fingolimod (Gilenya). This once-daily oral medication reduces the relapse rate of MS. Fingolimod is a unique medication that binds to many different types of body cells. It traps white blood cells in lymph nodes so that they can't enter the brain and cause new MS lesions.
People with heart disorders or related conditions can't use fingolimod. It can temporarily slow the heart rate, so the first dose must be taken under medical supervision. It also requires monitoring of vision because of a risk of buildup of fluid in the macula, an area in the center of the retina. For that reason, people with diabetes generally shouldn't use fingolimod.
Teriflunomide (Aubagio). Teriflunomide has been approved in two doses, 7 milligrams (mg) and 14 mg, taken once daily. It's generally well tolerated at both doses. Possible side effects include headache, diarrhea, nausea, elevation in liver enzymes and hair thinning.
Pregnant women and people with liver conditions shouldn't use teriflunomide.
Dimethyl fumarate (Tecfidera). Also known as BG-12, dimethyl fumarate is taken twice daily. Common side effects include flushing and gastrointestinal problems, such as diarrhea and nausea. Its coating is designed to reduce gastrointestinal problems, and taking it with food also can help relieve them.
Diroximel fumarate (Vumerity). This twice-daily capsule is similar to dimethyl fumarate but typically causes fewer side effects. It's approved for the treatment of relapsing forms of MS.
Cladribine (Mavenclad). This drug has been shown to be effective in reducing MS relapses and new brain lesions. It was also approved for secondary-progressive MS. Possible side effects include increased risk of developing infections.
Siponimod (Mayzent). This once-daily oral medication can reduce relapse rate and help slow the progression of MS. It's also approved for secondary-progressive MS.
Possible side effects include viral infections, liver problems and low white blood cell count. Other possible side effects include changes in heart rate, headaches and vision problems.
There's no way to know which treatments will work best for you or how your disease will progress. Recommendations are based on several factors, including:
- Recent MS activity, including recent attack frequency, severity and recovery
- How much neurological damage you have
- The severity of lesion damage to the brain and spinal cord based on an MRI
- Drug availability and cost
- Other illnesses you have or medications you take that might interact with MS therapy
- Adverse side effects from the MS drugs
- Monitoring requirements
- Your own preferences regarding type of therapy (oral or injectable, for example)
- Wanting to conceive a child
Shared decision-making between you and your doctor is the best approach to your MS treatment plan. Once you start a DMT, it's important that you continue taking your medication as prescribed. Be sure to report new symptoms to your doctor, who will monitor your response and possibly switch your medication if needed.
Your situation is unique, and the best treatment is one tailored to your needs.
June 05, 2020
- Olek MJ, et al. Disease-modifying treatment of relapsing-remitting multiple sclerosis in adults. https://www.uptodate.com//contents/search. Accessed March 12, 2020.
- Disease-modifying therapies for MS. National Multiple Sclerosis Society. https://www.nationalmssociety.org/Programs-and-Services/Resources/The-MS-Disease-Modifying-Medications-(-pdf)?page=1&orderby=3&order=asc. Accessed March 12, 2020.
- Rae-Grant A, et al. Practice guideline recommendations summary: Disease-modifying therapies for adults with multiple sclerosis. Neurology. 2018; doi:10.1212/WNL.0000000000005347.
- Starting disease-modifying therapies for multiple sclerosis. American Academy of Neurology. https://www.aan.com/Guidelines/home/GuidelineDetail/898. Accessed March 12, 2020.
- FDA news release: FDA approves new oral treatment for multiple sclerosis. U.S. Food & Drug Administration. https://www.fda.gov/news-events/press-announcements/fda-approves-new-oral-treatment-multiple-sclerosis. Accessed March 12, 2020.