Multiple Sclerosis (MS)
There is evidence that multiple sclerosis (MS) is more than a demyelinating disorder. Disability results from axonal damage that occurs early in the disease. This damage is irreversible. This has given major impetus to the new philosophy of early treatment with disease modifying therapies. As of 2014, there are four injectable medications, two medications given by infusion therapy (intravenous therapy), and one oral treatment approved by the FDA for relapsing forms of MS. These medications were approved based on stringently designed and monitored clinical trials.
A number of potential new agents are undergoing clinical trials. If approved, there will be numerous MS drug therapy options. Unfortunately, there are currently no approved drug therapies for progressive MS, which is a relatively uncommon form of the disease. Treatment of MS relapses is an important part of disease management.
The international standard of care is the use of corticosteroids, given either orally or via intravenous administration. Cortocosteroid drugs include prednisone, dexamethasone, solumedrol, and methylprednisolone. These are usually prescribed for a limited time (during a relapse) with specific instructions about how to take the medication and precautions about managing side effects. These medications are not recommended for long-term use in multiple sclerosis.
Disease modification therapy represents a promising new approach to the treatment of MS. The following treatment options should be discussed with your healthcare provider.
Interferon Beta Products
Interferon B-1a (Avonex), given either intramuscularly or subcutaneously (injected into the muscle or under the skin), or interferon B-1b (Betaseron given under the skin), are standard treatments for relapsing MS. These medications consist of proteins that interfere with the migration of damaging white blood cells into the central nervous system (brain and spinal cord), thus inhibiting damage and reducing relapse rates. Side effects can be managed with appropriate education and skills development in terms of self-injection and other valuable strategies. Nursing support for successful self-injection is important with these medications. Injection schedules vary with each product. People who use interferon will be taught the appropriate timing of treatments.
Glatiramer Acetate (Copaxone)
Glatiramer acetate is a synthetic polypeptide (similar to a protein). It resembles natural myelin basic protein. It’s thought to work by diverting the attention of damaging white blood cells to itself rather than to the myelin sheaths that insulate nerve cells and their underlying axons. This medication is self-injected daily. The most frequently encountered problems are skin reactions due to daily injections and a rare reaction resembling an allergic response that is self-limited. Patients must be trained to administer injections properly. In 2014, the FDA approved a higher-dose version of the drug. It can be administered three times a week, rather than daily.
Natalizumab is administered via intravenous infusion every four weeks to people with relapsing forms of MS. It is a monoclonal antibody that blocks the migration (movement) of damaging white blood cells into the brain and spinal cord. People who are undergoing this treatment must be carefully monitored for side effects and infections that are unique to this therapy. This treatment has been associated with a rare but potentially fatal brain infection known as progressive multifocal leukoencephalopathy (PML). Because of this risk, since 2012 the FDA has recommended that patients be tested for evidence of exposure to the virus linked to this disease before taking natalizumab.
Mitoxantrone is a chemotherapeutic agent originally used to treat cancer. It can be given by intravenous infusion to people with worsening relapsing MS. It suppresses the activity of immune system cells that may be involved in attacking myelin. It is administered once every three months. Possible side effects include possible heart damage and a form of cancer. Due to these and other potentially serious side effects, mitoxantrone is prescribed less frequently now, since the advent of natalizumab.
This is the first oral medication approved for relapsing MS. This treatment causes damaging white blood cells to remain within lymph nodes in the body, thus reducing the chance they will enter the brain and spinal cord and cause damage. People who are taking this medication are monitored prior to starting treatment and throughout the course of treatment for potential side effects such as heart problems, vision problems, and other serious complications.
This newer oral medication is related to a similar drug used to treat rheumatoid arthritis, an autoimmune disease. By inhibiting a crucial enzyme needed by white blood cells, it can decrease the activity of white blood cells involved in attacks on nerve cell myelin. Teriflunomide should not be taken by women who are pregnant or who might become pregnant. Like other potent disease-modifying agents, this drug can increase the risk of certain infections. Patients should be tested for tuberculosis before starting therapy, and must have regular monitoring of liver function and blood pressure.
Dimethyl Fumarate (Tecfidera)
This is another relatively new oral medication for the control of MS disease progression among patients with relapsing-remitting MS. A related compound has been used in Europe to treat psoriasis, an inflammatory skin condition. The exact mechanism of action is unclear, but it’s thought that Tecfidera works by interfering with the activity of certain immune system cells and chemicals. Taken by mouth twice daily, the drug has been shown to reduce the risk of relapse by 49 percent, compared to inactive placebo. Common side effects include flushing and reduced white blood cell count. Taking the drug with food may reduce the incidence of flushing.
Dalfampridine was approved by the FDA in 2010 to improve walking in patients with MS. It is available as a tablet taken by mouth. It works by blocking tiny pores in nerve cells called potassium channels. This may help improve nerve impulse conduction in nerve cells that have undergone demyelination due to MS. One study showed that the drug improves walking speed among MS patients, compared to placebo, by about 25 percent. It also improves leg muscle strength. Side effects may include urinary tract infection, insomnia, headache and nausea. In 2012, the FDA issued a warning that seizures have been reported among some patients starting therapy with the drug. Kidney function testing is recommended to minimize this risk.
A number of treatments are approved for "early" MS. Also called CIS, or clinically isolated syndrome, it is diagnosed on the basis of clinical expertise and evidence on MRI. Interferon beta-1a (given intramuscularly), interferon beta 1-b (given subcutaneously), and glatiramer acetate are all FDA-approved for the treatment of this early form of the disease.
Once a person has begun to manage their disease with these treatments, it is important to take medications on schedule, to manage side effects appropriately, to adhere to monitoring procedures, and to sustain a good relationship with a healthcare professional or healthcare team.
Inflammation is typical during MS relapse, and it can lead to many of the secondary symptoms associated with MS. Corticosteroids are often used to treat MS symptoms. They are inflammation-fighting drugs used to reduce the severity of attacks. Corticosteroids for MS treatment include:
- dexamethasone (intravenous)
- methylprednisolone (intravenous)
- prednisone (oral)
These are commonly administered to MS patients to ease suffering due to painful muscle stiffness or muscle spasms. Drugs commonly prescribed to treat spasticity include:
- baclofen (Lioresal)
- onabotulinumtoxin A (Botox)
- cyclobenzaprine (Flexeril)
- dantrolene (Dantrium)
- diazepam (Valium)
- tizanidine (Zanaflex)
Drugs to Treat Fatigue
Ongoing fatigue is a common problem for MS patients. Your doctor may prescribe a medication such as amantadine, modafinil (Provigil), or fluoxetine (Prozac) to help with this problem.
Drugs to Treat Dysesthesia
Dysesthesia, which literally means "bad sensation", is a type of pain often experienced by MS patients. It can feel like ongoing burning, wetness, itching, electric shock, or "pins and needles." To treat pain and dysesthesia, your doctor may prescribe:
- amitriptyline (Elavil)
- clonazepam (Klonopin)
- gabapentin (Neurontin)
- nortriptyline (Pamelor)
- phenytoin (Dilantin)
Depression is a complex mental health problem that is common during the course of multiple sclerosis. Some studies have shown that people with MS are more likely to be clinically depressed (the most severe form of depression) than the general population. Drugs used to treat depression include:
- bupropion (Wellbutrin)
- duloxetine hydrochloride (Cymbalta)
- fluoxetine (Prozac)
- paroxetine (Paxil)
- sertaline (Zoloft)
- venlafaxine (Effexor)
Drugs to Treat Constipation
Constipation is another common symptom of MS. It can be managed with the help of medications such as:
- bisacodyl (Dulcolax)
- docusate (Colace)
- magnesium hydroxide (Milk of Magnesia)
- psyllium hydrophillic mucilloid (Metamucil)
Drugs to Treat Bladder Dysfunction
Bladder dysfunction occurs in at least 80 percent of people with MS. It may include frequent urination, incontinence, hesitancy in starting urination, or frequent nocturia (nighttime urination). Bladder dysfunction is usually readily managed. Drugs to treat this symptom include:
- darifenacin (Enablex)
- oxybutynin (Ditropan)
- prazosin (Minipress)
- tamsulosin (Flomax)
- tolterodine (Detrol)
Drugs to Treat Erectile Dysfunction
Although both men and women with MS tend to have higher rates of sexual dysfunction than the general population, erectile dysfunction in men is relatively common. Oral medications that may be prescribed to help treat erectile dysfunction include:
- sildenafil (Viagra)
- tadalafil (Cialis)
- vardenafil (Levitra)
Older drugs, which must be injected directly into the penis, are also available. These drugs have fallen out of favor with the advent of oral medications for erectile dysfunction. They include:
- alprostadil (Prostin VR)
Written by: June Halper, MSN, APN-C, FAAN, MSCN
Medically reviewed by George Krucik, MD, MBA