Treatment for Multiple Sclerosis
Although there is still no cure for multiple sclerosis (MS), effective therapies are available to modify the course of the disease, treat attacks or relapses and manage symptoms. Additionally, there are many exciting research studies in MS to improve disease outcomes. It is important to know that the majority of people with MS do not become severely physically disabled and MS is not considered a life-limiting disease. With recent advances, more than two-thirds of people who have MS remain able to walk without assistance. Though some will need an assistive device, such as a cane, to help with weakness and balance problems sometime in their lives.
Medications to Treat Multiple Sclerosis
Because MS is the result of a malfunctioning immune system, many drug therapies for the disease target the immune system's activities. Medications used to treat MS work to reduce relapses of the disease and slow its progression by preventing further damage to myelin, the protective sheath covering nerve cells. Types of MS drugs to reduce disease progression, called disease-modifying therapies, include:
- Corticosteroids — The most common treatment for multiple sclerosis relapses, corticosteroids are cortisone-like medicines that reduce the inflammation associated with an MS relapse. Some treatments are given in the clinic by IV, and others can be taken orally in pill form. Corticosteroids may lower the body's resistance to infections, and can have other serious side effects. Patients taking these medications should be closely monitored. These are not typically used for prevention of MS attacks.
- Interferons — Interferons are a group of proteins very similar to those naturally produced in the body which act to control the immune system. These types of drugs – known under the brand names Betaseron, Extavia, Avonex, Rebif and Plegridy – appear to slow the rate at which MS symptoms worsen over time. They are all administered by self-injection either under the skin or in the muscle (Avonex only). Serious side effects, such as damage to thyroid, kidneys or liver, are rare but patients must be carefully monitored. More common side effects include flu-like symptoms and reactions at the injection site.
- Glatiramer acetate (Copaxone or Glatopa) — This drug is made of an artificial protein that resembles a natural protein in myelin. It is not known exactly how the medication works, but it is thought to help prevent the body's immune system from attacking the myelin coating that protects nerve fibers. It is approved only for relapsing-remitting MS and is given by injection once a day or three times per week. This appears to slow the number of new lesions (tissue damage) as seen on MRI, without the flu-like symptoms that interferons can cause. Side effects may include injection site reactions and uncommon and brief episodes of flushing and shortness of breath after injection.
- Mitoxantrone (Novantrone) — Novantrone is a drug that works by suppressing the immune system. It can slow damage to nerve-covering myelin and reduce the relapse rate in people with relapsing-remitting, progressive-relapsing and secondary-progressive MS. Novantrone is rarely given now due to dose-related severe heart damage and risk for blood cancers (leukemia), and so it is usually reserved for patients with advanced disease. Other immunosuppressive drugs which have been studied for treating MS but are not FDA approved for this indication include Azathioprine (Imuran, Azasan), Rituximab (Rituxan), and Methotrexate (Rheumatrex, Trexall).
- Natalizumab (Tysabri) — This drug works differently than other MS drugs in that it inhibits white blood cells from passing into the brain and spinal cord where they can attack myelin. This action is thought to result in fewer brain lesions that cause MS symptoms. Tysabri has been proven to reduce the frequency of MS flare-ups and slow disease progression. While it is also shown to improve mental function and physical disability in some patients, it is generally reserved for people who see no results from or cannot tolerate other types of treatments. This is because Tysabri increases the risk of progressive multifocal leukoencephalopathy (PML) - a rare brain infection that is usually fatal.
- Fingolimod (Gilenya) — Gilenya (pronounced "jih-len-ee-ah"), the first oral drug for treating MS, received FDA approval in 2010. Gilenya works by trapping white blood cells within the lymph nodes, preventing them from attacking the protective myelin on nerve cells and causing the symptoms of MS. Gilenya is generally safe and well-tolerated, but there are safety issues that must be addressed in treatment. Because of this, the treatment is usually reserved for patients who are not tolerating other medications or who are not experiencing good control of their MS.
- Teriflunomide (Aubagio) — Aubagio was the second oral drug approved for relapsing forms of MS in 2012. This drug blocks rapidly growing cells, such as lymphocytes (B+T cells) in immune diseases. This is generally well tolerated, but there are safety concerns including possible liver injury which requires once-monthly blood tests for the first six months of therapy. This medication is contraindicated in those looking to become pregnant as it is a known cause of birth defects (for both women and men).
- Dimethyl Fumarate (Tecfidera) — Tecfidera was the third oral drug for treating MS, and has a novel mechanism of action as an anti-inflammatory and possible neuroprotective agent. This medication has some issues with tolerability with known and common side effects of hot flashes, flushing and abdominal cramping. The safety profile is very good and very limited long term side effects have been seen.
- Alemtuzumab (Lemtrada) — This is considered a third-line medication, given its long list of possible side effects and adverse effects and long duration of action. This medication has had some great treatment responses, and is given one time per year as an infusion. These benefits must be weighed by the adverse effects, most notably causing other auto-immune conditions such as thyroid disease and blood disease (immune-thrombocytopenia).
- Daclizumab (Zinbryta) — Similar to Lemtrada, Zinbryta is approved by the FDA as a third-line medication, with recommendations for use only after a patient fails two or more MS disease modifying therapies because of its risks and side effects. This medication is a self-administered injection, once per month, and is fairly well tolerated. Although skin rashes and injection site reactions are common. Because of the risks for liver injury and inducing other auto-immune diseases, a blood test once per month prior to the next injection is recommended.
Learn more about MS disease modifying therapies:
- National MS Society – MS Medications
- MS Association of America – Long-Term Treatments for MS
- PatientsLikeMe.com – Patient reported medication experiences
Complementary Therapy for MS
In addition to lifestyle factors that are important for MS treatment, there are a number of additional medications, dietary choices and supplements which may be of benefit for symptom management or disease modification. Some additional medications with research benefits for MS management include:
- Dalfampridine (Ampyra) — This medication is approved for use in MS patients, not for preventing disease from worsening, but for improving some symptoms including walking speed and arm dexterity. This medication likely works by speeding up the nerve electrical responses that are impaired by MS lesions. About 25 percent of people who used this in clinical trials seem to have a significant improvement in some of these symptoms.
- Low-dose Naltrexone — A daily 4.5 mg dose was studied in a few small studies in MS patients. The study showed some subjective benefit in quality of life in some patients, but no overall improvement in disease activity. This is thought to reduce inflammation and has been studied in other autoimmune or inflammatory disorders with limited benefit also. The lowest pill dose is 50 mg, and for a low dose this has to be sent to compounding pharmacy.
- Statins — High-dose statins, commonly used cholesterol medications such as Simvastatin or Atorvastatin, used for reduction of heart disease, may have some benefit at reducing progression in patients with MS – although studies are conflicting. A discussion with your health provider about your risk for heart disease is an important part of your overall health.
Treating MS Symptoms with Physical Therapy
Physical therapy may help mobility problems caused by MS symptoms.
While physical therapy doesn't eliminate the actual symptoms of MS (such as weakness, tremors, tingling, numbness and other physical problems), therapy can help patients to compensate for the changes brought on by MS. Such treatments can include learning about new techniques, strategies, and equipment that are designed to facilitate movement.
Physical therapy can also be very helpful for combating the tightness, pain or weakness MS patients feel in muscles and joints. Exercises that can be taught and performed at home are designed to increase independence and quality of life by improving function and relieving pain. Physical therapy can also help with balance problems, coordination and fatigue.
Virginia Mason also offers comprehensive, nationally recognized neurological rehabilitation services. Our highly experienced physicians, psychologists and therapists are dedicated to working with patients and their families, as key members of the rehabilitation team.