My MS Log

How is multiple sclerosis treated?

There are many issues for the patient and physician to consider in treating multiple sclerosis. Goals may include reducing the number of attacks, improving recovery from attacks, and attempting to slow further progression of the disease (treatment with disease-modifying drugs). An additional goal is relief from complications due to the loss of function of affected organs (treatment with drugs aimed at specific symptoms). Most neurologists will consider treatment with disease-modifying drugs once the diagnosis of multiple sclerosis is established. Many will begin treatment at the time of the first multiple sclerosis attack, since clinical trials have suggested that patients in whom treatment is delayed may not benefit as much as patients who are treated early. Finally, utilizing support groups or counseling may be helpful for patients and their families whose lives may directly be affected by multiple sclerosis.

Once goals have been set, initial therapy may include medications to manage attacks, symptoms, or both. An understanding of the potential side effects of drugs is critical for the patient because sometimes side effects alone deter patients from drug therapy. Patients may choose to avoid drugs altogether or choose an alternative drug that may offer relief with fewer side effects. A continuous dialogue between the patient and physician about the medications is important in determining the needs for treatment.

Drugs known to affect the immune system have become the primary focus for managing multiple sclerosis. Initially, corticosteroids, such as prednisone (Deltasone, Liquid Pred, Deltasone, Orasone, Prednicen-M) or methylprednisolone (Medrol, Depo-Medrol), were widely used. However, since their effect on the immune system is non-specific and their use may cause numerous side effects, corticosteroids now tend to be used to manage only sudden, severe multiple sclerosis attacks.

Interferon

Since 1993, medications that alter the immune system, particularly interferons, have been used to manage multiple sclerosis. Interferons are protein messengers that cells of the immune system manufacture and use to communicate with one another. There are different types of interferons, such as alpha, beta, and gamma. All interferons have the ability to regulate the immune system and play an important role in protecting against viral infections. Each interferon functions differently, but the functions overlap. The beta interferons have been found useful in managing multiple sclerosis. Interferon beta-1b (Betaseron®) was the first interferon approved to manage RR-MS in 1993. In 1996, interferon beta-1a (Avonex®) gained FDA approval for RR-MS.

Overall, patients treated with interferons experience fewer relapses or a longer interval between relapses. Clinical trials have also shown effects on slowing the accumulation of disability. The most common side effect is a flu-like syndrome that includes fever, tiredness, weakness, chills, and muscle aches. This syndrome tends to occur less frequently as therapy continues. Other common side effects are injection site reactions, changes in blood cell counts, and abnormalities of liver tests. Regular liver tests and blood counts are recommended for patients receiving interferon beta-1b. With the concomitant use of analgesics and local skin measures, the tolerability to interferons has increased.

Clinical trials of interferon beta drugs in patients with the first attack of multiple sclerosis showed that in this early patient population, these drugs delay the onset of the second attack. Avonex® is administered intramuscularly once a week, Betaseron® is administered subcutaneously every other day, and Rebif® is administered subcutaneously three times per week.

Available interferon betas include:

IFN beta-1b (Betaseron®) that is used for the treatment of relapsing forms of multiple sclerosis, to reduce the frequency of clinical relapses. Patients with multiple sclerosis in whom efficacy has been demonstrated include patients who have experienced a first clinical episode and have MRI features consistent with multiple sclerosis.

IFN beta-1a (Rebif®) that is used for the treatment of patients with relapsing forms of multiple sclerosis to decrease the frequency of clinical relapses and delay the accumulation of physical disability. Efficacy of Rebif® in chronic progressive multiple sclerosis has not been established.

IFN beta-1a (Avonex®) that is used for the treatment of patients with relapsing forms of multiple sclerosis to slow the accumulation of physical disability and decrease the frequency of clinical relapses. Patients with multiple sclerosis in whom efficacy has been demonstrated include patients who have experienced a first clinical episode and have MRI features consistent with multiple sclerosis. Safety and efficacy in patients with chronic progressive multiple sclerosis has not been established.

Other medications

Glatiramer acetate

Glatiramer acetate (Copaxone) is another disease-modifying drug that is approved for reducing the frequency of relapses in RR-MS. Glatiramer acetate is a synthetic (man-made) amino acid mixture that may resemble a protein component of myelin. It is thought that the immune system reaction against myelin in multiple sclerosis may be blocked by glatiramer acetate. A reaction occurring immediately after the injection of glatiramer acetate is common, affecting one out of 10 patients. The reaction may involve flushing, chest pain or tightness, palpitations, anxiety, shortness of breath, tightness in the throat, or hives. The reaction usually resolves within 30 minutes and requires no treatment. Some patients may be at risk of developing lipoatrophy, inflammation and destruction of tissue beneath the skin at the site of injection. Glatiramer acetate is used for reducing the frequency of relapses in patients with relapsing-remitting multiple sclerosis.

Natalizumab

Natalizumab (Tysabri®) is a drug approved by the FDA to treat multiple sclerosis. Natalizumab is a monoclonal antibody against VLA-4, a molecule required for immune cells to adhere to other cells, penetrate the blood brain barrier and enter the brain. It is administered via monthly intravenous infusions. It carries a warning for a potentially fatal disease, progressive multifocal leukoencephalopathy (PML), a viral infection of the brain that usually leads to death or severe disability. For this reason only patients who have signed up for treatment under a controlled drug distribution program can get this treatment.

Natalizumab is used as monotherapy for the treatment of patients with relapsing forms of multiple sclerosis to delay the progression of physical disability and reduce the frequency of clinical relapses. The safety and efficacy of natalizumab beyond two years are unknown. Because natalizumab increases the risk of PML, it is generally recommended only for patients who have had an inadequate response to, or are unable to tolerate alternate multiple sclerosis therapies.

Mitoxantrone

Mitoxantrone (Novantrone®) is also approved by the FDA for the treatment of multiple sclerosis. Mitoxantrone is a chemotherapy drug that carries the risk of serious cardiac side effects or cancer. Because of these serious side effects, physicians tend to reserve its use for more advanced or worsening cases of multiple sclerosis.

Mitoxantrone is used for reducing neurologic disability and/or the frequency of clinical relapses in patients with secondary (chronic) progressive, progressive relapsing, or worsening relapsing-remitting multiple sclerosis (for example, patients whose neurologic status is significantly abnormal between relapses). Mitoxantrone is not used in the treatment of patients with primary progressive multiple sclerosis.

How are the manifestations of multiple sclerosis treated?

There are numerous medications that are used to manage complications associated with multiple sclerosis. The following table lists common complications, examples of drug and non-drug therapy, and comments about complications and/or management.

Table. Multiple sclerosis complications with examples of drug and non-drug management (this list is not exhaustive; some of the drugs listed below are used to treat multiple sclerosis symptoms even though they have not been FDA-approved for this particular purpose)

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