While steroids do not affect the course of MS over time, they can reduce the duration and severity of attacks in some patients. The mechanism behind this effect is thought to relate to their ability to kill lymphocytes – which are white blood cells that are though to drive disease activity in MS – along with other benefits. Because steroids can produce numerous untoward side effects (acne, weight gain, seizures, psychosis), they are not recommended for long-term use.
One of the most researched and established treatments for MS are naturally occurring antiviral proteins known as beta-interferons. Five forms of beta interferon (Avonex, Betaseron, Extavia, Plegridy, and Rebif) are currently approved by the Food and Drug Administration for treatment of relapsing-remitting MS. Beta interferon is self-administered as an injection by the patient at home and has been shown to reduce the number of exacerbations and may slow the accumulation of physical disability. When attacks do occur, they tend to be shorter and less severe. In addition, MRI scans suggest that beta interferon can decrease myelin destruction. Generally speaking, this form of treatment confers a moderate amount of protection from disease activity with a very safe side effect profile.
Glatiramer acetate (GA, Copaxone) is another self-administered injection which decreases relapses. It has two formulations, a daily injection and a three times per week injection. Although some monitoring is required for both the interferons and glatiramer acetate, the safety of these drugs is well-established and these drugs continue to be viewed as the mainstay treatments for most MS patients early on in the disease.
More recently approved drugs for use in MS appear to improve upon the efficacy of the interferons or glatiramer, but do so at a slightly increased risk of adverse events. Thus, drugs like natalizumab (Tysabri), fingolimod (Gilenya), and mitoxantrone (Novantrone) are typically used as 2nd or 3rd line drugs when needed or for patients with aggressive disease early on in their disease course. Fingolimod was the first oral drug for MS, approved by the U.S. Food and Drug Administration in 2010. The drug works by keeping some white blood cells in the lymph glands and preventing them from entering into the central nervous system. Opportunistic infections and cardiovascular side effects including low heart rate and increased blood pressure can limit the use of this drug in some persons. Also, it carries a risk of rare side effects of macular edema, serious infections including progressive multifocal leukocencephalopathy(PML), a viral infection of the brain, and a possible link to increased skin malignancies. Mitoxantrone is a chemotherapeutic drug which receives limited use due to toxicity concerns about leukemia and heart failure but can arrest a very aggressive MS disease course when needed.
Teriflunomide (Aubagio) was approved by the FDA in 2012 for MS. Like fingolimod, it is administered as a daily pill. Teriflunomide has modest efficacy on preventing relapses but may help more with progressive disability. It carries a risk of hair thinning, new onset of high blood pressure, and reactivation of TB in patients who have previously had TB.
Dimethyl fumarate (Tecfidera) was approved in 2013 by the FDA for relapsing forms of MS. It is a pill taken twice a day and the most common side effects includes episodes of flushing, which are self-limited, and gastrointestinal symptoms, which can include, pain, nausea, and diarrhea. The medication is better tolerated with taken with food. Dimethyl fumarate seems to have modest treatment effect in stopping the disease with relatively minor side effects with a rare risk of serious adverse events. Dimethyl fumarate can be associated with opportunistic infections, including PML in very rare cases.
Natalizumab (Tysabri) is an IV infusion that is administered every 28 days. It seems to be one of the more effective treatments for relapsing forms of MS. It does carry a rare but serious risk of PML, up to 1.5% per year in higher risk populations. We are able to define an individual’s risk of this infection based on bloodwork and other parameters. Also, infusion reactions can occur that are typically mild but can be serious in rare events. It works very well for many patients.
Alemtuzumab (Lemtrada) is one of the newest approved medications for relapsing forms of MS. This medication has been shown to be one of the most effective treatments for MS but carries greater risks than the other approved MS therapies. Patients treated with alemtuzumab carry a moderate risk for developing autoimmune thyroid disease, and lower risks for autoimmunity which can damage the platelets and kidneys. Other rare but serious side effects of alemtuzumab include opportunistic infections, which occur because of immune suppression caused by the drug, and cancers. Most patients who are treated with this medication are patients who have either failed multiple prior treatments or have very aggressive disease early on in their course as it carries serious risks. It is given as a daily infusion for 5 days followed 12 months later by a daily infusion for 3 days for a total of 8 days of infusion and has been shown to be beneficial for many years at a time.
Scientists continue their extensive efforts to create new and better therapies for MS. Goals of therapy are threefold: to improve recovery from attacks, to prevent or lessen the number of relapses, and to halt disease progression.
Are Any MS Symptoms Treatable?
While some scientists look for therapies that will affect the overall course of the disease, others are searching for new and better medications to control the symptoms of MS without causing intolerable side effects.Many people with MS have problems with spasticity (muscle stiffness), a condition that typically affects the lower limbs more than the arms. Spasticity can occur either as a sustained stiffness caused by increased muscle tone or as spasms that come and go, especially at night. It is usually treated with muscle relaxants. Baclofen (Lioresal), the most commonly prescribed medication for this symptom, may be taken orally or, in severe cases, administered into the spinal cord canal via a pump. Many ‘traditional’ muscle spasm medications such as cyclobenzaprine (Flexeril), methocarbamol (Robaxin), metaxalone (Skelaxin), and tizanidine (Zanaflex) can help to relieve muscle spasms or tightness in patients with MS. Diazepam (Valium), clonazepam (Klonopin), and dantrolene (Dantrium) can also reduce stiffness and spasms. Although its beneficial effect is temporary, physical therapy may also be useful and can help prevent the irreversible shortening of muscles known as contractures. Surgery to reduce spasticity is rarely appropriate in MS.
Weakness and ataxia (incoordination) are also common in MS. When weakness is a problem, some spasticity can actually be beneficial by lending support to weak limbs. In such cases, medication levels that completely alleviate spasticity may be inappropriate. Physical therapy and exercise can also help preserve remaining function, and patients may find that various aids - such as foot braces, canes, and walkers - can help them remain independent and mobile. Further research is needed to find or develop effective treatments for MS-related weakness.
Trouble with walking is a major problem in people with MS. The drug dalfampridine (Ampyra) has been shown to improve walking, mostly by improving walking speed, in individuals with MS. It significantly improves walking in approximately half of MS patients who try it.
Visual symptoms related to new relapses can be improved with the help of short term steroids. This helps to speed up the recovery of vision. Visual rehabilitation efforts can be employed to help MS patients with long-standing vision impairment to better adapt to their environment. This treatment can be obtained through the Callahan Eye Foundation.
Fatigue, especially in the legs, is a common symptom of MS and may be both physical and psychological. Avoiding excessive activity and heat are probably the most important measures patients can take to counter physiological fatigue. However, it is important for MS patients to maximize their sleep quality by practicing good sleep ‘hygiene’ – that is, going to sleep at the same time every night, reducing interruptions or distractions in the bedroom, no caffeine after lunch, wake up at the same time every day, and sleeping in a cool and dark room. Also, many MS patients find considerable benefit from afternoon naps of only 20-30mins. If psychological aspects of fatigue such as depression or apathy are evident, antidepressant medications may help. Other drugs that may reduce fatigue in MS patients include amantadine (Symmetrel), methylphenidate (Ritalin), amphetamine-dextroamphetamine (Adderall), modafanil (Provigil), and armodafanil (Nuvigil).
People with MS may experience several types of pain. Muscle and back pain can be helped by aspirin or acetaminophen and physical therapy to correct faulty posture and strengthen and stretch muscles. The sharp, stabbing facial pain known as trigeminal neuralgia is commonly treated with carbamazepine or other anticonvulsant drugs. Intense tingling and burning sensations are harder to treat. Some people get relief with antidepressant drugs that have been shown to help this type of pain while others may respond to antiepileptic medications that have been shown to reduce this type of ‘neuropathic’ pain. Many patients with MS have difficulty with impaired bladder function. Urinary problems are sometimes the result of infections that can be treated with antibiotics. Several medications are available to treat the symptoms of MS related bladder dysfunction. The most common bladder problems encountered by MS patients are urinary frequency, urgency, and incontinence. A small number of patients, however, retain large amounts of urine. In these patients, catheterization (manual drainage of the bladder with a small tube) may be necessary. Some surgical procedures may be beneficial in select situations.
MS patients with urinary problems may be reluctant to drink enough fluids, leading to constipation. Drinking more water and adding fiber to the diet usually alleviates this condition. Sexual dysfunction may also occur, especially in patients with urinary problems. Men may experience occasional failure to attain an erection. Penile implants, injection of the drug papaverine, and electrostimulation are techniques used to resolve the problem. Women may experience insufficient lubrication or have difficulty reaching orgasm; in these cases, vaginal gels and vibrating devices may be helpful. Counseling is also beneficial, especially in the absence of urinary problems, since psychological factors can also cause these symptoms. For instance, depression can intensify symptoms of fatigue, pain, and sexual dysfunction. In addition to counseling, the physician may prescribe antidepressant or antianxiety medications. Pseudobulbar affect, the uncontrollable syndrome of laughing or crying at inappropriate times, out of sync with a person’s true emotions, can be treated with a drug called dextromethorphan/quinidine (Nuedexta).
Tremors in MS are often resistant to therapy, but can sometimes be treated with drugs or, in extreme cases, surgery. Investigators are currently examining a number of experimental treatments for tremor.