Choices and Risks

The battle against multiple sclerosis has advanced considerably in recent years. A number of drugs are effective in alleviating symptoms and helping combat relapses. However, as with any disease, it’s crucial to understand the benefits and risks of specific treatment options and choose the therapy that’s best for you. Taking no action is riskier.

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Avonex (interferon beta-1a)

Company: Biogen Idec

Description: Avonex treats relapsing MS. Avonex is an interferon. Interferons are messenger proteins produced by the body to modulate the immune response. Avonex works to prevent the immune system from attacking the central nervous system. This reduces the number and severity of exacerbations,

Treatment: Intramuscular injection (into the muscle) once a week.

Side effects: Flu-like symptoms that typically lesson over time. Less common: depression, mild anemia, liver abnormalities, allergic reactions, heart problems, thyroid problems.

Results: Avonex was introduced in 1996. It has proven to be relatively safe and effective in reducing the progression of physical disability due to MS. It reduces the occurrence of relapses and reduces the number of lesions appearing on follow-up MRI. Further studies of relapsing-remitting MS have shown a significant reduction in the number of patients who have progressed to an EDSS disability score above 6.0.

Aubagio (teriflunomide)

  • Company: Sanofi/Genzyme Corp.
  • Description: Aubagio is a disease-modifying therapy approved to treat active relapsing-remitting MS (RRMS) that is neither highly active nor rapidly evolving severe RRMS. It is a pyrimidine synthesis inhibitor that reduces the profliferation of T and B cells and certain immune system messenger chemicals.
  • Treatment: Oral tablet, taken once daily.
  • Side effects: 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 undergo regular monitoring of liver function and blood pressure.

Results: This is a relatively new medication for the treatment of relapsing forms of MS. It is a tablet taken once a day, by mouth. Trials show that it can significantly reduce the rate of relapses. The higher dose of the drug has also been shown to reduce disability progression, compared to placebo. Teriflunomide is related to a similar drug used to treat the autoimmune disease, rheumatoid arthritis. By inhibiting a crucial enzyme needed by white blood cells, it can decrease the activity of white blood cells (T cells and B cells) involved in attacks on nerve cell myelin.

Betaseron (interferon beta-1b)

Company: Bayer HealthCare Pharmaceuticals

Description: Betaseron is an interferon. By modulating the immune response in the central nervous system it reduces inflammation, along with the number and severity of exacerbations. It also stabilizes the lesion area.

Treatment: Subcutaneous injection (under the skin), every other day.

Side effects: Flu-like symptoms that typically lessen over time. Injection site reactions. Less common: depression, liver abnormalities, allergic reactions, low white blood cell count, seizures, thyroid problems.

Results: Betaseron was approved in 1993 and works by reducing the body’s immune response that attacks nerve cells. The drug is made from human blood plasma; interferon beta is a protein that’s normally manufactured by the body. The drug has demonstrated a long history of success. One trial found that the drug reduces onset of MS by 50 percent in the first two years among patients who display clinically isolated syndrome (CIS).

Copaxone (glatiramer acetate)

Company: Teva Neuroscience

Description: A manmade protein that resembles natural myelin protein. It blocks the activity of T-cells, which play a role in demyelination. Although the way it works is not entirely clear, it is believed to act as a sort of decoy for the attention of inflammatory cells. Copaxone may also stimulate cellular activity that prevents damage to nerve fibers.

Treatment: Subcutaneous injection (just beneath the fat layer of the skin), once every day. In early 2014, the FDA approved a new, higher dose that may be injected just three times per week.

Side effects: Injection site reactions, dilation of blood vessels, chest pain, tremor. In a small minority of patients, a post-injection reaction may occur consisting of anxiety, chest pain, heart palpitations, flushing, and shortness of breath, lasting about 15 minutes. It usually resolves on its own, and occurs only once.

Results: The synthetic polypeptide, approved in 1996, has a consistent track record of improving immune system function and reducing exacerbations. Only one third of patients who take the drug experience a progression of MS. In addition, 57 percent have achieved stable or improved EDSS scores. Copaxone is the only RRMS therapy that doesn’t require routine monitoring.

Extavia (interferon beta-1b)

Company: Novartis Pharmaceutical

Description: Extavia, which is identical to Betaseron, reduces inflammation and the frequency and severity of attacks.

Treatment: See Betaseron.

Side effects: See Betaseron.

Results: See Betaseron.

Gilenya (fingolimod)

Company: Novartis Pharmaceutical

Description: Gilenya, referred to as a sphingosine 1-phosphate receptor modulator (S1P-receptor modulator), mimics the structure of naturally occurring cell surface receptors and thus blocks destructive T-cells from leaving the lymph nodes. This prevents them from crossing the blood-brain barrier and attacking nerves in the central nervous system.

Treatment: Capsule taken orally every day.

Side effects: Headache, flu-like symptoms, diarrhea, back pain, liver enzyme elevations and cough. Less common: slowed heart rate following the first dose, infections, swelling within the eye that could affect vision. Upon first starting the drug, patients must undergo heart function monitoring for at least six hours, due to the possibility of dangerously slow heartbeat. Should not be taken by people with preexisting heart disease.

Results: The drug, approved by the FDA in November 2010, is the first in a new class of immunomodulatory therapies that reduce damage to the central nervous system and enhance the repair of damaged neurons. Gilenya has demonstrated the ability to reduce relapse rates by 60 percent and reduce the progression of MS by up to 82 percent when measured with an MRI.

Novantrone (mitoxantrone)

Company: EMD Serono

Description: Novantrone, an immunosuppressant drug originally used to treat certain types of cancer, is also approved for use in patients with progressive-relapsing MS (PRMS), secondary progressive MS, and worsening relapsing-remitting MS. It has not been approved for the treatment of primary-progressive MS. The drug decreases lesions and stabilizes MS in some patients.

Treatment: IV infusion in a medical facility four times a year. Lifetime dosage limit is typically between eight to 12 doses over two to three years.

Side effects: Discolored urine following administration, infections, bone marrow suppression, nausea, hair thinning, bladder infections, mouth sores. It’s also necessary to monitor for signs of serious liver and heart damage, cardiac disease, and leukemia. Possible transient (blue) discoloration of the whites of the eyes and the urine. Due to the risk of cumulative damage to heart muscle, there is a lifetime limit on how much of the drug a patient may receive.

Results: The drug works by suppressing the immune system, thus decreasing inflammatory damage to the myelin sheath that surrounds nerves. It is used for relapsing-remitting, progressive-relapsing, and secondary-progressive forms of MS. Approved in 2000, the drug has a track record of improving EDSS scores and reducing relapses. In one clinical trial, 90 percent of patients taking the drug in combination with methylprednisolone showed no sign of lesions after six months.

Rebif (interferon beta-1a)

Companies: EMD Serono and Pfizer.

Description: Approved for relapsing types of MS. Rebif is a type of interferon; a synthetic version of a natural immune system protein that modulates the immune system to reduce inflammation..

Treatment: Subcutaneous injection (beneath the fat layer under the skin) three times per week.

Side effects: Flu-like symptoms that usually lessen over time. (This reaction may be lessened by taking an over-the-counter nonsteroidal anti-inflammatory drug (NSAID) during the 24-hour period surrounding treatment.) Injection site reactions. Less common: liver abnormalities, depression (including thoughts of suicide), allergic reactions, low white blood cell count, seizures.

Results: The drug, which has more than 17 years of clinical trial and patient use, is designed for those with RRMS. Patients who took the drug for two years showed a 78 percent reduction in lesions, a reduced need for steroid treatments, and fewer exacerbations. Rebif Rebidose was approved by the FDA in early 2013. It consists of a color-coded auto-injector for enhanced convenience.

Tysabri (natalizumab)

Companies: Biogen Idec and Elan Pharmaceuticals

Description: Tysabri is approved for relapsing types of MS. Generally used for patients that have seen no improvement with other MS treatments. Tysabri is a laboratory-produced monoclonal antibody that inhibits the activity of lymphocytes that attack the central nervous system.

Treatment: IV infusion in a medical facility every four weeks.

Side effects: Headache, fatigue, depression, urinary tract infections, lower respiratory tract infections, joint pain, and chest discomfort. Less common: allergic or hypersensitive reactions after infusion (fever, rash, dizziness, nausea, flushing, low blood pressure, breathing difficulties, chest pains). It’s also critical to test for PML, a rare but often-fatal brain disease caused by the JC virus. For this reason, patients who receive Tysabri should participate in safety monitoring programs at registered infusion centers so that it’s possible to watch for adverse events and provide immediate treatment, if needed.

Results: Studies show that Tysabri, which was approved by the FDA in 2005, can repair damage to the myelin sheath, slow progression of disability and help reduce relapses. It is also effective in reducing fatigue and improving language processing, cognitive function and vision loss related to RRMS. Eighty-seven percent of RRMS patients (previously treated with other therapies) who took Tysabri showed stable or improved MRI scans after 18 to 24 months. EDSS scores were stable or improved in 59 percent of patients.