An Update on Multiple Sclerosis Treatments

June 27, 2017
Heidi Moawad, MD

Here is a quick primer on currently available MS therapies for partners in a patient’s healthcare team and also for patients.

There are more treatment options than ever before for patients with multiple sclerosis.

Patients with MS are often cared for by a neurologist and one or more other physicians or therapists as well. Neurologists often note that these healthcare providers can become overwhelmed by the availability of so many treatment options and worried about whether their patient is receiving optimal therapy.

MS TREATMENT OPTIONS

Interferon beta-1b (Betaseron, Extavia). The first drug that was approved for treatment of MS, interferon beta-1b is an injectable medication. This medication reduces inflammation in the central nervous system. The most common side effects include injection site reactions and GI symptoms, such as stomach pain, constipation, and diarrhea.

Interferon beta-1a (Avonex, Rebif)An injectable medication, interferon beta-1a reduces inflammation, possibly through the reduction of T cell production and also reduction of inflammatory cells in the CNS. Like interferon beta- 1b, it is believed to prevent the crossing of inflammatory cells through the blood brain barrier. The most common side effects include injection site reactions and fevers.

Peginterferon beta-1a (Plegridy). Similar to interferon, this injectable is believed to have an extended duration. The most common side effects include injection site reactions, fevers. and joint pain.

Glatiramer acetate (Copaxone, Glatopa). This immunomodulator is used to prevent relapses, is injected subcutaneously. The most common side effects include injection site reactions, fevers, double vision, weakness, and swelling of the hands or feet.

Daclizumab (Zinbryta). This subcutaneously injected medication is believed to reduce T cells. The suggested mechanism is through binding to the IL- 2 T cell receptors. The most common side effects include upper respiratory tract infection and skin rash.

Dimethyl Fumarate (Tecfidera). This oral medication works as an anti-inflammatory by blocking cytokine induction. The most common side effects include flushing, rash, and GI symptoms.

Fingolimod (Gilenya). This oral medication is believed to lower the number of lymphocytes in the blood by binding to T cells. The most common side effects include headaches and flu-like symptoms. This medication may cause some patients to have abnormal liver tests.

Teriflunomide (Aubagio). Another oral MS therapy, this immunomodulatory drug is believed to work by inhibiting the proliferation of T cells and B cells. It may cause abnormal liver tests, flu-like symptoms, and thinning hair.

Mitoxantrone (Novantrone). This IV antineoplastic agent is believed to work by disrupting the synthesis of DNA. A relatively powerful agent, it may cause hair loss, menstrual changes, and GI symptoms.

Natalizumab (Tysabri) is administered IV. It is an antibody that is reported to prevent leukocyte entry into the body’s organs. Tysabri can cause headaches and joint pain, and has also been associated with progressive multifocal leukoencephalopathy, a rare disorder affecting the brain that causes seizures and paralysis and may progress to death.

Ocrelizumab (Ocrevus). This agent was approved for the treatment of relapsing remitting MS in March 2017. It is administered by IV infusion and is believed to act against B cells. Thus far, there is little clinical experience with Ocrevus, but studies showed infusion reactions such as pruritus, rash, urticaria, and erythema as well as an increase in respiratory infections and herpes virus infections.

Alemtuzumab (Lemtrada). This a recombinant humanized IgG1 kappa monoclonal antibody is an infusion therapy that decreases the number of immune cells. Considered a powerful agent, Lemtrada is generally reserved for patients who have had inadequate response to other disease modifying agents. Therapy may cause rash, headaches, and fevers.

PATIENT CONCERNS

So far, all available therapies for MS target the immune system. Issues that are often relevant during patient discussions include medication efficacy and safety, as well as the specific medication’s history in a patient’s form of MS. Patients most often express concern regarding the potential effect of therapy on fertility and whether or not it is safe to become pregnant during or at any time after having taken the medication.

Some patients have a preferred route of drug administration. (Some prefer oral medications, while others may favor the IV or IM route.) When you discuss MS treatment with your patients, do they express strong preferences based on the route of administration?

 

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