A Guide to Multiple Sclerosis Medications | BY HEIDI

A Guide to Multiple Sclerosis Medications | BY HEIDI


     


    Multiple sclerosis (MS) is a chronic disease that damages the protective sheath (myelin) around the nerve cells of the central nervous system. The central nervous system is like a communication pathway between the brain and the body, and it allows the brain to control most bodily and mental functions.


    MS affects each person differently. While some people are mildly affected, others lose their ability to write, speak, or walk. There are four types of MS: primary progressive, secondary progressive, relapsing-remitting, and clinically isolated syndrome (CIS). Each type has a different progression and symptom pattern.



    Since there is no cure for MS, medications are used to help slow disease progression or manage its symptoms.


    There are several types of medications that can be used to treat MS, including chemotherapy drugs, anti-inflammatories, immunosuppressive drugs that are designed to hinder the action of the immune system, and steroids.


    In some cases, medications for MS are categorized based on how they are administered, what they do, and what symptoms they manage. Read on to discover the various forms of medications for MS and how they help people with the disease.



     How Multiple Sclerosis Is Treated

    Disease-Modifying Therapies (DMTs)

    Several kinds of disease-modifying therapies (DMTs) may change the course of MS. Depending on how effective the medications are for any given patient, the length of treatment varies, but it can range from a few months to years.



    How well a patient tolerates a medication's side effects and how well the medication manages their symptoms are factors that doctors use to determine whether or not a patient will stay on a specific treatment or switch to a new type of medication.1



    A doctor will monitor a patient to see if any new lesions develop and in which are areas of the brain the nerve cells have been stripped of myelin. If new lesions do develop, a doctor may switch a patient to a new DMT.


    Drugs that modify the course of the disease can be injected, taken orally, or infused through the bloodstream using a needle into a vein (intravenous).


    Injections and Infusions

    There are several injectable medications that have been approved by the Food and Drug Administration (FDA) to treat MS.



    Interferon Beta Injectable Drugs


    Interferon beta injectable drugs were the first DMTs approved for MS treatment. The injections help change the course of active relapsing-remitting MS and secondary progressive MS. If a person has relapsed or presents with new lesions caused by damage to the nerves, they are a good candidate for interferon beta injectable drugs.





    These medications hinder the ability of white blood cells, which are immune cells, from getting into the brain and spinal cord to cause more damage to the nerves. Since it is thought that MS is driven by autoimmunity (meaning the immune system begins to attack itself), blocking the action of these immune cells can slow the progression of the damage that is caused by MS.2


    Injectable Medication Methods

    Each type of injectable medication has its own method and results, but you will give yourself the injections. The administration schedules for these medications are:


    Interferon beta 1a (Rebif, Avonex): Injected into a muscle once per week

    Interferon beta 1b (Extavia, Betaseron): Injected under the skin every other day

    Peginterferon beta 1a (Plegridy): Injected under the skin once every two weeks2

    Interferon beta injectable drugs are considered to be safe for many people with MS. However, they do come with some side effects, including:2


    Flu-like symptoms

    Headaches

    Chills

    Pain or a rash at the injection site

    Fever

    Muscle aches and pains

    Natalizumab (Tysabri)


    Natalizumab is a type of antibody, which are specialized proteins designed to identify foreign invaders in the body. This medication is used to block a specific type of immune cell (T lymphocytes) from getting into the brain and spinal cord.3


    This medication is typically used to treat active disease in people with secondary progressive or relapsing-remitting MS, but it is sometimes given to people with CIS.


    Natalizumab is administered as an infusion into the bloodstream by a healthcare provider once every four weeks. The infusion itself will last an hour.


    Side effects of natalizumab can include:3


    Headache

    Urinary tract infection

    Lung infection

    Muscle aches and pains

    Abdominal pain

    Vaginal infection (vaginitis)

    Depression

    Diarrhea

    Nausea

    Rash

    Joint stiffness

    Fatigue 

    Glatiramer Acetate (Glatopa, Copaxone)


    Glatiramer acetate is a synthetically made substance that is meant to resemble a specific protein in myelin. The medication works by tricking the immune cells into attacking it instead of the body's myelin. It is typically used to treat relapsing-remitting MS or CIS.4


    You will inject this medication yourself either once every day or once three days per week. It's important to follow your provider's directions for taking this medication to make sure you are giving yourself the correct dose.


    The most common side effects of glatiramer acetate are a rash or pain at the injection site.4


    Alemtuzumab (Lemtrada)


    Alemtuzumab is not a first-line therapy for MS. It is intended for people who have tried more than two other MS medications without relief from their symptoms or slowing of the progression of the disease.


    The medication works by reducing the number of immune cells (B and T lymphocytes) in the body, which can help reduce inflammation and decrease damage to the nerve cells.



    Alemtuzumab is given as an infusion, similar to glatiramer acetate. However, the alemtuzumab infusion takes four hours.


    The treatment regimen for alemtuzumab is:5


    First course: Once per day for five days in a row

    Second course: Once per day for three days in a row

    12 months with no infusions

    Subsequent courses: Once per day for three days in a row as needed, at least 12 months after the last dose of any previous courses

    The side effects of this drug can include:


    Fever

    Chills

    Dizziness

    Shortness of breath

    Nausea and/or vomiting

    Mild rash or itching

    Flushing

    Serious Side Effects

    In some cases, alemtuzumab can cause serious side effects, including:6


    Stroke

    Tears in arteries that supply the brain with blood

    Cancers

    Low blood counts

    Liver inflammation

    Serious infections

    Inflammation of the gallbladder

    Lung tissue swelling

    Autoimmunity

    Mitoxantrone Hydrochloride


    Mitoxantrone hydrochloride was originally approved as a chemotherapy treatment, but it is also used to treat MS. The medication works by suppressing the action of the immune system cells that attack and damage myelin. Typically, relapsing-remitting and secondary progressive MS are treated using mitoxantrone hydrochloride.


    The medication is administered through an IV infusion once every three months by a healthcare provider. The infusion lasts roughly five to 15 minutes.7


    The most common side effects of mitoxantrone hydrochloride include:7


    Changes in or lack of menstrual periods during treatment

    Nausea

    Thinning hair

    Urine that is blue-green in color for roughly 24 hours after the infusion was given

    Upper airway and urinary tract infections

    Headaches

    Constipation

    Vomiting

    Diarrhea

    Serious Side Effects

    In some cases, there are permanent and serious side effects associated with the use of mitoxantrone hydrochloride, including congestive heart failure, leukemia, and liver damage.7


     What Medications May Help Ease My MS Fatigue?

    Ofatumumab (Kesimpta)


    Ofatumumab is the newest treatment for MS. It can be used to treat CIS, relapsing-remitting MS, and secondary progressive MS.


    The medication works by singling out certain harmful immune cells (B lymphocytes) and reducing how many there are in the body. This leads to less damage because there are fewer B cells targeting the myelin in the brain and spinal cord.8


    This injectable medication is administered under the skin (subcutaneously) once per week for three weeks, followed by a one-week break, and then once a month after that. The first injection should be done under the guidance of a healthcare professional. After that, you will inject the medication yourself.


    Some common side effects of ofatumumab include:9


    Redness, pain, itching, or swelling at the injection site

    Fever

    Headaches

    Muscle aches and pains

    Chills

    Fatigue

    Chest infections

    Colds and head colds

    Cold sores

    Urinary tract infections

    A decrease in the molecules that help protect the body against infection (antibodies)

    Ocrelizumab (Ocrevus)


    Ocrelizumab is an infusion medication that treats CIS, relapsing-remitting MS, and primary progressive MS. It works similarly to ofatumumab, as it reduces the number of B lymphocytes in the body, thereby decreasing the number of cells that are available to damage the myelin.


    According to research, ocrelizumab is the first medication that has been shown to significantly slow the disability progression in people with primary progressive MS.10


    The medication is given as an infusion. Two separate infusions will be given, with a two-week break between them, with regular infusions being given once every six months. Each infusion will take between three and four hours.


    Side effects of ocrelizumab can include:11


    Headaches

    Rash

    Fever

    Nausea

    Cold sores

    Cough

    Adverse Effects

    Ocrelizumab hinders the function of the immune system, which means that it can make a person more susceptible to illnesses like the flu, sinus infections, bronchitis, and viral infections. Skin infections and herpes infections have also been seen in people taking ocrelizumab.11


    Oral Medications

    There are also oral medications that have been approved by the FDA to treat MS, including:12  


    Dimethyl fumarate (Tecfidera): Taken in oral capsules twice per day, this medication is thought to modulate the immune system to help lessen the damage to the brain and spinal cord nerves. 

    Cladribine (Mavenclad): This compound drug suppresses the action of the immune system by reducing the number of B and T lymphocytes in the body, which prevents further damage to nerve cells.

    Diroximel fumarate (Vumerity): This drug is taken twice per day. After it is broken down in the body, it converts into monomethyl fumarate and has the same immune-modulating action as dimethyl fumarate.  

    Fingolimod (Gilenya): This drug works by preventing white blood cells from getting into the central nervous system by trapping them in the bean-shaped structures involved in immune function (lymph nodes).

    Monomethyl fumarate (Bafiertam): Taken twice per day, this oral medication works similarly to dimethyl fumarate and diroximel fumarate by modulating the immune response and reducing inflammation.

    Ozanimod (Zeposia): This drug traps white blood cells in the lymph nodes, which keeps them from passing into the central nervous system where they can cause further damage.

    Siponimod (Mayzent): Similar to ozanimod, siponimod retains white blood cells in the lymph nodes to ensure they do not get into the central nervous system. It also reduces inflammation.

    How Often Are Oral Medications Taken?

    Oral medications will be taken differently depending on the type, but typically, they are taken either once or twice per day.


    Medications for MS Symptoms

    Some MS medications are designed to treat or manage MS based on specific symptoms or other conditions that arise.12


    Bladder Symptoms


    Bladder symptoms affect up to 80% of people with MS.13 Medications that treat or manage bladder dysfunction tend to work by relaxing bladder muscles to prevent the over-contraction of the muscles. They can also reduce muscle spasms, block connections between the nerves and muscles in the bladder, and help to encourage the flow of urine.


    Medications that can treat bladder symptoms in MS include:


    Darifenacin (Enablex): This medication works by relaxing the bladder muscles to help prevent contractions that lead to the inability to control the bladder (incontinence). It also helps prevent the urgent and frequent need to urinate.

    Desmopressin (DDVAP nasal spray): Given as a nasal spray, this hormone affects the kidneys. It helps to control the frequent need to urinate.

    Imipramine (Tofranil): This antidepressant can help with urinary frequency and incontinence.

    Mirabegron (Myrbetriq): This medication treats an overactive bladder by relaxing the muscles in the urinary tract and reducing bladder spasms.

    Onabotulinumtoxin A (Botox): This neurotoxin provides relief by blocking connections that can make muscles tight and cause spasms.

    Oxybutynin (Ditropan, Ditropan XL, Oxytrol): This medication works by decreasing the number of muscle spasms that occur in the bladder, thus relieving urinary symptoms that are caused by the spasms.

    Prazosin (Minipress): This medication is typically used to treat high blood pressure, but for people with MS, it can help to promote the flow of urine.

    Solifenacin (VESIcare): This drug is designed to treat overactive bladder.

    Tamsulosin (Flomax): By relaxing the muscles in the bladder and the prostate, this medication can help to promote urine flow in people with MS.

    Tolterodine (Detrol): This medication is in the same class as solifenacin and helps to relax bladder muscles and prevent an overactive bladder.

    Emotional Changes


    Some people with MS may experience abrupt emotional symptoms that might not be appropriate for the situation they are in—for example, laughing or crying uncontrollably. Dextromethorphan + quinidine (Nuedexta) is a combinational therapy that helps to treat these episodes.


    MS and Emotional Changes

    Roughly 10% of people with MS will experience uncontrollable bouts of laughter or crying that are not related to any true emotion (pseudobulbar affect). An even smaller number of people with MS experience an unrealistically happy and out-of-touch-with-reality feeling (euphoria).


    Bowel Dysfunction


    Roughly 39% to 73% of people with MS experience bowel dysfunction.14 One of the most common bowel symptoms that people with MS experience is constipation.


    There are different types of medications that can be used to treat constipation, including laxatives, stool softeners, and bulking agents.


    Some laxatives that can be used for constipation caused by MS include:


    Bisacodyl (Dulcolax)

    Fleet enema

    Magnesium hydroxide (Phillips’ Milk of Magnesia)

    Stool softeners for constipation that is caused by MS include:


    Docusate (Colace)

    Glycerin suppositories

    Mineral oil

    The bulking agent that is most often used to treat MS-driven constipation is psyllium fiber (Metamucil).  


    Fatigue


    Over 80% of people with MS experience fatigue.15 Medications designed to treat fatigue include:


    Dextroamphetamine and amphetamine (Adderall): This medication stimulates the central nervous system to improve mental alertness.

    Amantadine (Gocovril, off-label): This antiviral medication is used off-label to treat MS fatigue, which means that it was not developed for this purpose. The reason for its action against fatigue is not clear; however, it helps some patients with MS feel more alert.  

    Methylphenidate (Ritalin): Another drug used off-label for MS fatigue, this medication helps to stimulate the central nervous system to encourage mental alertness.

    Modafinil (Provigil): This medication is designed to encourage a feeling of wakefulness. It was made to help treat obstructive sleep apnea and shift work sleep disorder but is used off-label to treat MS fatigue.

    Fluoxetine (Prozac, off-label): This medication is also used off-label for MS and can help improve fatigue. It is an antidepressant that is typically used to treat depression, obsessive-compulsive disorder, and panic attacks.

     Addressing 5 Common Fears About MS Treatment

    Pain and Dysesthesia


    Up to 75% of people with MS experience some form of chronic pain or abnormal sensations (dysesthesia).16 To help treat these feelings, medications include:


    Amitriptyline: This antidepressant helps treat pain and abnormal sensations in the arms and legs that can develop after certain pathways are damaged in the course of MS.

    Clonazepam (Klonopin): Klonopin is typically used to treat seizures and panic attacks, but it can also be used to manage pain in people with MS when they have not gotten relief from other treatments.

    Gabapentin (Neurontin): This anti-seizure medication can help control pain that is caused by damage to the nerve cells in the brain and spinal cord.

    Nortriptyline (Pamelor): Another antidepressant that is used to treat pain symptoms in MS, this medication is thought to help with pain in the arms and legs.

    Phenytoin (Dilantin): This medication is typically used to treat seizures, but it can also help manage pain in people with MS.

    Itching


    Itching is a symptom that many people with MS experience. They also can have abnormal sensations such as pins and needles or burning, stabbing, or tearing pains.


    The medication that is most often used to treat itching in people with MS is hydroxyzine (Vistaril), an antihistamine that is typically used to prevent allergy symptoms.

    Depression


    Nearly 50% of people with MS develop depression.17 The most common antidepressant medications given to people with MS are selective serotonin reuptake inhibitors (SSRIs).


    SSRIs block nerves from absorbing the neurotransmitter serotonin. When too much serotonin is absorbed by nerve cells, there is not enough left to continue sending messages between nerve cells, which leads to symptoms of depression.


    Some examples of SSRIs that are used to treat depression in people with MS include:12


    Citalopram (Celexa)

    Duloxetine (Cymbalta)

    Venlafaxine (Effexor)

    Paroxetine (Paxil)

    Fluoxetine (Prozac)

    Sertraline (Zoloft)

    Some people also take medications from the aminoketone class of antidepressants. Bupropion (Wellbutrin SR, Wellbutrin XL) is the medication of this class that is most often used to treat depression in MS patients.


    Bupropion works similarly to SSRIs except that it blocks the nerves from absorbing too much of the neurotransmitters norepinephrine and dopamine.


    Sexual Dysfunction


    Sexual dysfunction can affect anyone with MS and can include erectile dysfunction, the inability to achieve orgasm, and low libido.


    The medications used to treat sexual dysfunction in people with MS focus on erectile dysfunction and include:


    Sildenafil (Viagra)

    Tadalafil (Cialis)

    Vardenafil (Levitra)

    Alprostadil (MUSE, Prostin VR, Caverject, injectable)

    Avanafil (Stendra)

    Papaverine (off-label)

    Alternative Treatments

    Treatments for other types of sexual dysfunction in MS vary and can include antidepressants, an increase in the use of lubricant while engaging in sexual activity, cognitive behavioral therapy (CBT), couples counseling, and the use of sexual aids.


    Tremors


    Although tremors do not occur in everyone with MS, as many as 58% of people with the disease will experience the symptom at some point.18


    Tremors can present in different ways, such as a shaky voice, shaking that affects the arms and hands, and difficulty holding tools or utensils.


    Some medications that can be used to treat tremors in people with MS include:  


    Baclofen

    Clonazepam (Klonopin)

    Dantrolene (Dantrium)

    Diazepam (Valium)

    Onabotulinumtoxin A (Botox)

    Tizanidine (Zanaflex)

    Spasticity and Muscle Stiffness


    The same medications that are used to treat tremors in MS can also be used to manage muscle stiffness and spasticity, including:


    Baclofen (Lioresal): This medication acts on the nervous system to help reduce cramping, spasms, and tightness in the muscles that are caused by spasticity.

    Cyclobenzaprine (Amrix): This medication is designed to treat muscle spasms in people with conditions like carpal tunnel syndrome and tendinitis, but it can also relieve muscle tightness in people with MS.

    Dantrolene (Dantrium): This muscle relaxant relieves cramping, spasms, and tightness.

    Diazepam (Valium): This medication is a benzodiazepine (also known as central nervous system depressants). The main action of benzodiazepines is to slow the nervous system, which can help to relieve muscle spasms and spasticity.

    Onabotulinumtoxin A (Botox): The neurotoxin blocks connections that can help relieve muscle tightness and spasms.

    Tizanidine (Zanaflex): This drug relieves spasms, cramping, and tightness of muscles.

    Vertigo and Dizziness


    According to the National Multiple Sclerosis Society, vertigo and dizziness are common symptoms of MS.19 It can lead to people feeling off-balance or lightheaded, and may even increase the risk of people falling.


    To treat vertigo and dizziness in people with MS, the medication meclizine (Antivert) is used. It is used to address dizziness, nausea, and vertigo in a variety of conditions.


    Difficulty Walking and Gait Changes


    Because of the way MS affects the central nervous system, many people with the condition can develop trouble walking and with mobility. When someone's ability to move around is affected by MS, their treatment plan will need to be adjusted to address it.


    The medication that is typically used to help with walking or gait changes in people with MS is dalfampridine (Ampyra), an oral medication that works by improving signals in the nerves that have become damaged because of MS.20


    Summary

    It can be challenging to cope with the various symptoms of MS, especially if they change as the disease progresses. However, there are a variety of different treatment options that can help manage symptoms and slow the progression of the disease, which will lead to a higher quality of life.

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