Over the past 10 years, there has been considerable progress in the treatment of multiple sclerosis. There are now several therapeutic options available to patients. Your doctor will discuss these treatment options in detail and recommend treatments that are appropriate for your care. The following medications are available for patients:
- Intravenous methylprednisolone (Solumedrol) is used to treat relapses or exacerbations. It is given for 3 to 7 days with the premise that treatment decreases the duration and severity of the present attack.
- Intravenous methylprednisolone may be given on a once monthly basis as an addition to a baseline medication.
Injectable MS Disease Modifying Treatments
These are several medications which are used as first-line treatments for multiple sclerosis. The major benefical effects of these medications is the prevention of relapses and new MRI lesions.
- Betaseron (interferon beta 1b) a subcutaneous injection taken every other day.
- Avonex (interferon beta 1a) an intra muscular injection taken once weekly. A low dose of interferon beta 1a.
- Rebif (interferon beta 1a) a subcutaneous injection taken three times per week.
- Copaxone (glatiramer acetate) a subcutaneous injection taken on a daily basis.Immunomodulating therapy is commonly initiated when the diagnosis is first established. All of these medications work to re balance the activated immune response and delay the progression of the disease by decreasing the attack rate and activity on brain MRI.
As of May 2013, there are three oral medications (pills) available for the treatment of MS. Here is a link to a table summarizing these treaments. The names of these medications are:
- Gilenya – pill taken once a day
- Aubagio – pill taken once a day
- Tecfidera – pill taken twice a day
In some cases first line therapy with disease modifying treatments may not adequately control disease. Below are some of the second-line options available in these cases.
- Methotrexate is used typically in conjunction with either immunomodulators or monthly steroids. Methotrexate is used at higher doses as chemotherapy for cancer but at lower doses for diseases such as multiple sclerosis and rheumatoid arthritis. This medication may be used in patients with progression on a single medication. Methotrexate is taken once a week in pill form or as a subcutaneous injection. Liver function tests have to be monitored closely and alcoholic beverages should be avoided while taking this medication.
- Cyclophosphamide (Cytoxan) is an intravenous infusion given with methylprednisolone once monthly for one year then tapered over the next two years. It is typically given over a three-year protocol. At times, this protocol is extended to four or five years. Cyclophosphamide is a chemotherapy drug used in a lower dose in diseases such as multiple sclerosis and lupus nephritis. Cyclophosphamide is used in patients who are progressing and require aggressive stabilization of their disease. White blood cell counts are monitored for adequate medication dosing. Urine cytology must be monitored due to the long-term risk for bladder cancer.
- Mitoxantrone (Novantrone) is an intravenous infusion given every three months. Mitoxantrone is a chemotherapeutic drug used at a lower dose for multiple sclerosis. Mitoxantrone has a lifetime dose limitation after approximately two years. Mitoxantrone is used in patients progressing on immunomodulators and require aggressive stabilization. White blood cells have to be monitored for adequate dosing. Cardiac function by echocardiogram must be monitored due to risk of cardiac toxicity.
- Natalizumab (Tysabri) is given by monthly intravenous infusion. It is always administered as monotherapy, and it is contraindicated to use this medication in combination with other immunomodulatory or immunosuppressant therapies with the exception of intravenous steroid infusions given for relapses. It is effective in reducing the number of new relapses and helps to slow disease progression. The side effects include possible allergic reactions at the time of infusion, and an increased risk of infections. Use of Natalizumab is associated with an increased risk of developing a disease called progressive multifocal leukoencephalopathy (PML), which is a viral illness affecting the brain, and is generally fatal.
- There are a variety of other medications that have been shown to have some effect in reducing MS relapses or MRI lesion formation in small studies. These medications are approved for use in other diseases and are occasionally used “off label” in the treatment of MS. These include Daclizumab (Zenapax), Rituximab (Rituxan) and mycophenolate mofetil (Cellcept). Your doctor will discuss whether any of these treatments may be appropriate in your care.