How MS is treated
by Amanda Gardner
There’s no question that multiple sclerosis is frustrating, with varying and often unpredictable symptoms that seem to throw curve balls at people with MS.
But in less than two decades MS has gone from an essentially untreatable disease to one that has almost a dozen medications that slow the progression of the disease (known as immune-modulating medications), in addition to multiple other drugs that relieve symptoms.
Here are the different options, from simple walking to sophisticated biological therapies, that people with MS can choose from:
Once upon a time, experts recommended against exercise for people with MS, believing that it would exacerbate fatigue and speed progression of the disease. Now we know that exercise is not only notharmful, but can be beneficial to strength, cognitive functioning, and overall quality of life.
A landmark 1996 study found that exercise even improved bladder and bowel control. And just being physically active with shopping and gardening (as much as the disease will allow) can be enormously beneficial as well.
As the hallmark lesions associated with MS accumulate in the brain, cognitive function (such as memory), can suffer. Medications don’t seem to affect this aspect of the disease, but cognitive rehabilitation strategies such as memory retraining do.
A small study published in 2012 found not only behavioral improvements but also enhanced brain activation as measured by functional magnetic resonance imaging in patients who underwent a 10-session intervention to boost memory.
Speech pathologists can help MS patients not only with speech difficulties, such as long pauses or slurred language, but also with a potentially more serious problem: swallowing.
Swallowing difficulties, caused by damage in the areas of the brain that control muscles in this area, can potentially lead to choking and even aspiration pneumonia, in which bits of inhaled food trigger lung infections. Simple changes, like altering the texture of food a person is eating, can help.
The ancient Chinese practice of Tai Chi is being used by some people with MS, even those in wheelchairs, to help with balance and improve proprioception. (Proprioception is how we perceive ourselves in space.)
The deep breathing, relaxation, and measured movements of yoga can also help. Some people with MS find that acupuncture is effective, although there have been no formal clinical trials on this topic.
Injections of this bacterial toxin are typically associated with removing frown lines and wrinkles, but they’re now also proving useful in alleviating bladder and bowel problems among people with MS. Common symptoms of MS include incontinence, constipation, and difficulty emptying the bladder, due to problems with the relevant muscles.
Botox can calm these muscles so that the body removes waste more efficiently. “It’s sort of the same reason that Botox does some of its cosmetic magic, but for a different purpose,” says Nicholas LaRocca, Ph.D., vice president of healthcare delivery and policy research at the National Multiple Sclerosis Society (NMSS).
Approved in September of 2012, Aubagio (teriflunomide) is the most recent addition to the list of immune-modulating medications for MS. Taken as a once-a-day pill, Aubagio can actually slow progression of the disease by targeting the immune system. But the drug has two black-box warnings, alerting doctors and patients that it can cause liver toxicity and can cause major birth defects.
Generally women who take Aubagio and want to get pregnant will have to undergo chelation therapy to remove the drug from their body, says Leticia Tornes, M.D., a neurologist with the University of Miami Miller School of Medicine. Aubagio can linger in the body for as long as two years.
Unlike immune-modulating drugs such as Aubagio, steroids aren’t used to treat the disease itself, only to treat exacerbations or “flare ups.” These are episodes in which old symptoms reappear or new symptoms appear for the first time.
Steroids, one of the first drugs ever used to manage relapses, can be given orally or intravenously. Intravenous steroids seem to have the most benefit with the fewest side effects.
Like Aubagio, Gilenya (fingolimod) is another immune-modulating drug that can actually affect the disease process underlying MS, not just alleviate symptoms. Like Aubagio, it is taken once a day as a pill.
Older immune-modulating drugs are given as injections and reduce the annual risk of relapse by about 30%. Gilenya reduces the risk by 54%, says Dr. Tornes. The drug can slow heart rate so people need to have an electrocardiogram before their first dose and during the first six hours after.
There are four drugs in the interferon family which are used to treat MS: Avonex, Betaseron, Extavia, and Rebif. Interferons are produced by the immune system and dampen the overactive immune system that causes MS.
Each drug is dosed a little differently and administered at different time intervals, Dr. Tornes says. Interferons are given by injection and patients need to have their blood monitored carefully for liver and immune cell problems while taking these drugs.
Copaxone (glatiramer acetate) is given as a daily subcutaneous (under the skin) injection. It doesn’t cause the flu-like symptoms often associated with interferons, nor does it impact white-blood-cell counts or liver function.
“If a patient doesn’t like having their blood drawn or they travel a lot or it’s not convenient to have multiple blood draws, sometimes this is used instead of interferon,” Dr. Tornes says.
Originally developed to fight cancer, Novantrone (mitoxantrone) can combat multiple sclerosis by modulating the immune system. But fewer physicians are using it due to the risk of side effects, specifically leukemia.
Studies have put the risk of developing leukemia at 0.25% to 2.8% in different groups of patients with MS. “The risk of leukemia outweighs the benefit of the drug,” says Dr. Tornes. “It does work well but we think it’s too much risk.”
With an annualized relapse reduction rate of 67%, Tysabri (natalizumab) has the highest efficacy of any MS drug on the market right now, says Dr. Tornes. It is administered by an intravenous infusion once every four weeks.
Again, patients’ blood needs to be carefully monitored as Tysabri carries with it a higher risk of PML or progressive multifocal leukoencephalopathy, a severe brain infection. The good news is that there are now ways to determine if one is at high risk for this side effect, says Dr. Tornes.
Ampyra (dalfampridine) does not alter the disease course of MS, but it is used in MS patients to increase walking speed. “This will be used for a patient that is getting fatigued when they walk or whose walking is unbalanced,” Dr. Tornes says. “It works in about 30% of people.”
It is taken as a pill twice a day and is only available through a specialty pharmacy. The good news is that the drug company will provide it for free for three months. But if it works, it can cost you: $1,300 or more a month.
Nuedexta (dextromethorphan hydrobromide and quinidine sulfate) was approved in 2010 to treat pseudobulbar affect (PBA), a symptom of MS in which people experience uncontrolled bouts of emotion (such as laughter or crying) unrelated to the person’s actual mood.
It’s not clear how the drug works. It is given in capsule form.
This drug isn’t approved yet, which is why it doesn’t yet have a trade name, but it is presently before the U.S. Food and Drug Administration (FDA), says Timothy Coetzee, Ph.D., chief research officer for the NMSS.
Two studies published in 2012 in the New England Journal of Medicine found that BG-12 reduced relapses by about 50%. If all goes well, BG-12 may be approved as soon as December of 2012.
That would make it the 10th disease-modifying treatment on the market for people with MS, Coetzee says. It would also be the third disease-modifying treatment in pill form.
Lemtrada (alemtuzumab) is still in the pipeline and has run into some stumbling blocks with the FDA. Its earliest possible release date at this point would be mid-2013, says Coetzee.
Patients who took Lemtrada in trials had lower recurrence rates and less disability than patients taking Rebif. It requires five initial doses followed by infusions only once a year thereafter.
“It’s a very potent immune modifying drug that really reboots the immune system,” Coetzee says.