Treatments for relapsing-remitting multiple sclerosis (RRMS) are divided into two main categories: those aimed at reducing inflammatory attacks, also known as disease-modifying therapies (DMTs), and those aimed at reducing symptoms cause by MS attacks.
If given early in the course of the disease, DMTs reduce the frequency of MS attacks and delay disability. While there is no cure for MS, early and sustained use of DMTs give the best chance at maximizing overall quality of life. Together with using an RRMS therapy, lifestyle modifications such as regular exercise and eating a balanced diet can have a positive effect on your well-being.
Types of DMT treatment
There are three methods of delivery for DMTs: oral medication, injection, and intravenous infusion. Each is associated with a different lifestyle and requires a different approach for starting and maintaining the treatment.
For most therapies, the manufacturer provides patient assistance programs. In addition, using a reminder app is helpful for ensuring that you receive treatments in a timely fashion.
Because no treatment is approved for use during pregnancy, women who start MS therapy are highly recommended to discuss birth control with their primary care doctor.
Despite the challenges of adjusting to a new MS therapy, it’s possible to successfully start and maintain treatment with proper guidance from your MS neurologist.
|daily||glatiramer (Copaxone, Glatopa), 20 milligrams (mg)|
|every other day||interferon-beta-1a (specifically, Rebif) or interferon-beta-1b (Betaseron, Extavia)|
|three days per week||glatiramer (specifically, Copaxone in 40 mg dose)|
|once weekly||interferon-beta-1a (specifically, Avonex)|
|once every other week||peginterferon-beta-1a (Plegridy)|
|once per month||daclizumab (Zinbryta)|
All of these are injected under your skin, except Avonex, which is injected into muscle.
Those injectable therapies that are frequently administered are possibly the least convenient. This is because they require refrigeration, and taking them involves needles.
However, because interferons and glatiramer acetate are among the oldest therapies, their safety profile is best understood. And some injectables are the safest MS treatments available.
For most injection therapies, manufacturers offer in-home training with visiting nurses. The first dose may be given in a clinic or at home. Subsequent injections may be given at home. Medical providers from assistance programs may also make follow-up phone calls to answer questions and address concerns.
Prefilled syringes or auto-injectors require refrigeration. You’ll need to move them out of your fridge 30 minutes before administration to get them to room temperature. Travel kits with cold packs are also often available from the manufacturer.
Use a provided puncture-resistant container to dispose of bottles, syringes, and auto-injectors. Never reuse an injection kit unless explicitly instructed by the manufacturer.
To minimize injection-site reactions, such as soreness and bruising, associated with injections under your skin, rotate injection sites in your arms, abdomen, hips, and thighs.
You may give injections into muscle in your upper arms or thighs. Some find it useful to rotate injection sites in a clockwise or counterclockwise fashion.
Use a journal to record injection site rotations and any side effects. Be vigilant of side effects associated with injectable medications:
- Interferons often cause flu-like symptoms and may cause depressed mood or liver injury.
- Glatiramer acetate may cause skin dimples due to local loss of fat tissue (lipoatrophy), and less often causes flushing, palpitations, chest discomfort, or shortness of breath.
- Common side effects of daclizumab include rashes and elevated liver enzymes. Less common side effects include serious infections.
In addition, an injection may trigger an allergic reaction, though this is rare. Report any side effects to your MS neurologist or manufacturer-assigned nurse.
Oral DMTs are taken once or twice daily. Many prefer them over injections due to their ease of use.
Their effectiveness is in general considered higher than interferons and glatiramer acetate. And with proper screening and monitoring, oral therapies can be used safely without significant side effects.
Adjust to a daily oral therapy using a reminder app on your smartphone or a pillbox, and integrate it into your daily routine in the morning or evening.
All three oral therapies require a blood test prior to starting therapy, and then again once every three to six months depending on the treatment.
Treatment with fingolimod requires additional testing before or during the first dose: an eye exam to screen for macular edema, electrocardiogram, and cardiac monitoring for at least six hours with the first dose.
Teriflunomide requires blood monitoring monthly for six months, then every three to six months thereafter. Dimethyl-fumarate requires a blood test every six months. These tests are used to detect dangerously low levels of white blood cells that expose you to infection and injury to vital organs such as your liver.
The oral therapies each have side effects that may be managed differently:
- Dimethyl-fumarate may cause flushing or upset stomach, which you can reduce by eating food with high-fat content 30 minutes prior to taking the medication or by taking a baby aspirin (81 mg).
- Fingolimod may cause elevated blood pressure, so eating a balanced diet low in sodium is recommended.
- Teriflunomide may cause liver toxicity, so you’ll want to limit the amount of alcohol you drink with this therapy.
Intravenous infusion therapies
|once every three months||mitoxantrone (Novantrone)|
|once every six months||ocrelizumab (Ocrevus)|
|five consecutive days the first year, three consecutive days the next year||alemtuzumab (Lemtrada)|
All intravenous therapies are administered at a dedicated infusion center. This usually requires taking a half or full day off from work, as most infusion centers are only open during weekdays. It’s recommended to have someone come with you to the first infusion in case you experience side effects, or to all infusions if you have a physical disability.
An infusion treatment may take several hours to most of a day, depending on the medication and how you tolerate the infusion. Some people require pretreatment with medications to minimize side effects from the infusion. The infusion times for each of these four therapies are as follows:
- Natalizumab is infused over one hour.
- Mitoxantrone is administered over 15 minutes.
- Ocrelizumab is administered over three to four hours and requires premedication 30 to 60 minutes prior to the infusion.
- Alemtuzumab is administered over four hours and requires premedication given over 60 minutes.
The most common side effects are infusion-related reactions, including flushing, itching, headache, and fever. Because of this, there is usually a 30- to 60-minute post-treatment monitoring period to ensure tolerability. Plan to spend more time at the infusion center than anticipated, especially for the first treatment. Your favorite book or podcast will help the time go by.
Regular blood monitoring is a key part of safety for those receiving infusion therapy.
Treatment with natalizumab requires a blood test for John Cunningham virus antibody every three to six months while on therapy.
Alemtuzumab requires monthly blood tests for four years from the start of the first treatment, as well as an annual cervical smear for females.
Treatment with ocrelizumab currently only requires an initial blood test.
Mitoxantrone requires a blood test prior to each treatment (every three months).
Blood tests can be performed at the infusion center or a local diagnostic laboratory.
If you have difficulty keeping up with your treatment due to lifestyle challenges or side effects, speak to your MS neurologist rather than stopping a DMT on your own. Doing so without starting a new treatment may in some cases prompt a serious rebound MS attack.
Often there are ways to manage treatment side effects or to find a more convenient therapy, though it may be at a higher cost.
Disclosure: At the time of publication, the author has no financial relationships with MS therapy manufacturers.