Multiple Sclerosis

How is multiple sclerosis treated?

A range of medications is available to treat acute relapses, prevent relapses, delay disease progression and manage symptoms. All have been approved for use, although the efficacy and risks (e.g. infection) associated with each type of medication can vary. Your neurologist will discuss with you the benefits and risks of each treatment before prescribing medication to best suit your symptoms, stage of condition and unique needs.

Corticosteroids

Corticosteroids, also known as steroids or glucocorticosteroids, are prescribed during acute relapses to reduce the duration and severity of relapses. This is given via a drip into the vein (intravenously) usually for three to five days in the hospital, followed by a short course of oral corticosteroids upon discharge.

It is important to note that corticosteroids, especially at high doses, are not to be used on a long-term basis as they can cause side effects such as osteoporosis and diabetes.

Immunomodulatory agents

These medications are given to suppress inflammation in the brain and spinal cord, and have been shown to reduce relapse rates and disability.

There are now many new medications approved for this purpose, with differing effectiveness and side effects.

There is no ‘best’ drug for people with MS. The choice of medication is individualised and a decision should be made with your managing clinical team, taking into account factors such as degree of MS disease activity, type of MS, potential side effects, route of administration, child-bearing preferences, vaccination status and cost.

Types of immunomodulatory agents include:

• Interferon-beta
  Interferon-beta works mainly by reducing inflammatory molecules involved in MS while increasing anti-inflammatory compounds. It is given under the skin (subcutaneously), usually three times a week.

• Teriflunomide and Dimethyl Fumarate
  These medications reduce the number of activated immune cells and are taken orally on a daily basis.

• Fingolimod, Siponimod and Natalizumab
  These medications prevent activated immune cells from entering the brain and spinal cord. Fingolimod and Siponimod are taken orally on a daily basis, while Natalizumab is given monthly via a drip into the vein (intravenous). There is a slight risk of infection although this can be reduced by blood and imaging monitoring.

• Rituximab, Ocrelizumab and Ofatumumab
  These medications reduce B cells (a type of immune cell which play an important role in MS). Rituximab and Ocrelizumab are given via a drip into the vein (intravenously) every six months, while Ofatumumab is administered under the skin (subcutaneously) monthly. There is a slight risk of infection although this can be reduced by blood monitoring.

• Cladribine and Alemtuzumab
  Cladribine and Alemtuzumab are known as immune reconstitution therapies and work by first depleting the immune system, then allowing the immune system to ‘reset’ and then recover ability to respond to infections. They are given yearly for two years – orally for Cladribine and via a drip into the vein (intravenously) for Alemtuzumab. There is a slight risk of infection although this can be reduced by blood monitoring.
  

• Autologous haemopoietic stem cell transplantation
  Autologous haemopoietic stem cell transplantation is also a type of immune reconstitution therapy and involves chemotherapy to deplete harmful immune cells then allowing the immune system to ‘reboot’ and recover using stem cells taken from the blood of the same patient. This is a highly specialised procedure and for patients who do not respond to other treatments.
  

Symptomatic management

As symptoms of MS may persist even after a relapse, medications can be prescribed to manage symptoms such as pain, fatigue, stiffness, bowel and bladder issues, anxiety, depression and sexual problems.

Although these medications do not modulate the immune system, they are important in helping people with MS improve their quality of life.