Disease Modifying Drugs
There is evidence that multiple sclerosis (MS) is more than a demyelinating disorder. Disability is the result of axonal damage that occurs early in the disease, causing irreversible damage. This has given major impetus to the new philosophy of early treatment with disease modifying therapies. As of 2011, there are four injectable medication; 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.
There are also a number of potential new agents that are being studied at the present time and once they are approved, there will be many treatment options for MS. Unfortunately, progressive MS is the one disease course that does not have any approved therapies at the present time. It is also important to note that treatment of MS relapses is an important part of disease management. While there are no FDA approved treatment, the international standard of care is the use of corticosteroids administered either orally or via intravenous administration. You may see these treatments defined as prednisone, dexamethasone, solumedrol, or methylprednisolone. These are usually prescribed for a limited time period (during the period of a relapse) with specific instructions about how to take the medication and precautions to manage side effects. It is not recommended that these medications be prescribed long-term in multiple sclerosis.
Disease modification in MS has entered an exciting period with the following treatment options that should be discussed with your clinician prescriber.
Interferon Beta Products
Interferon B-1a (given either intramuscularly or subcutaneously—into the muscle or under the skin) or interferon B-1B (given under the skin) are now fundamentals of treatment for relapsing MS. These medications are protein substances 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. There are side-effects that people can manage with appropriate education and skills development in terms of self-injection and other valuable strategies. Nursing support to successful self-injection is important with these medications. Injection schedules vary with each product and those undertaking treatment will be taught the appropriate timing of treatments.
Glatiramer acetate is a synthetic polypeptide thought to resemble myelin basic protein thus diverting active damaging white blood cells to itself rather than to myelin and underlying axons. This medication is self-injected daily and has fewer side-effects. The most frequently encountered problems are skin reactions due to daily injections and a rare reaction resembling an allergic response that is self-limited. Again, education is vital to successfully manage this therapy.
Natalizumab if 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 PML.
Mitoxantrone is a chemotherapeutic agent that is given by intravenous infusion to people with worsening relapsing MS. Since the approval of natalizumab, mitoxantrone is being prescribed less frequently due to potential serious side effects.
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 of their entering into the brain and spinal cord and causing damage. People who are taking this medication are monitored prior to starting treatment and throughout the length of treatment for potential side effects such as heart problems, vision problems, and other serious complications.
It is also important to note that a number of treatments are approved for “early” MS. Also called CIS or clinically isolated syndrome, this is diagnosed on the basis of clinical expertise and evidence on MRI. Interferon beta-1a given intramusculary (IM) and interferon beta 1-b given subcutaneously and glatiramer acetate are all FDA approved for this early presentation of MS.
Once a person has begun to manage his or her disease with these treatments, it is important to take medications on schedule, manage side-effects appropriately, adhere to monitoring procedures, and sustain a good relationship with a healthcare professional or a healthcare team.
Medications to Treat MS Symptoms
Inflammation is very typical of MS relapses, and it can lead to many of the secondary symptoms associated with MS. As such, corticosteroids to ease inflammation and reduce the severity of attacks are one of the most common MS treatment options. Corticosteroids used to treat MS 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. Commonly prescribed drugs to treat spasticity include:
- baclofen (Lioresal)
- cyclobenzaprine (Flexeril)
- diazepam (Valium)
- tizanidine (Zanaflex)
Drugs to Treat Fatigue
Ongoing fatigue is a common problem for MS patients. Your doctor may prescribe you medications such as modafinil (Provigil) 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)
- gabapentin (Neurontin)
- nortriptyline (Pamelor)
- phenytoin (Dilantin)
Depression is a complex mental health problem that is very 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)
Drugs to Treat Constipation
Constipation is another common symptom of MS that is, luckily, usually easily managed with the help of medications such as:
- bisacodyl (Dulcolax)
- docusate (Colace)
- magnesium hydroxide (Milk of Magnesia)
- psyllium (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). Luckily, bladder dysfunction is usually easily managed. Drugs to treat this symptom include:
- darifenacin (Enablex)
- oxybutynin (Ditropan)
- 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 the most common of these types of problems. Medications sometimes prescribed to help treat erectile dysfunction include:
- sildenafil (Viagra)
- tadalafil (Cialis)
- vardenafil (Levitra)