Multiple Sclerosis (MS)


There is currently no cure for multiple sclerosis (MS). The treatment approaches that are available focus on delaying the progression of the disease, speeding recovery from exacerbations, and managing disease symptoms.1 The type of treatment that a patient will need depends on the severity of their disease and varies case-by-case. 

Disease-Modifying Treatments

Disease-modifying treatments for MS have all been tested in patients with relapsing-remitting multiple sclerosis (RRMS) and are approved for this disease course. Currently, there is only 1 disease-modifying treatment approved by the US Food and Drug Administration (FDA) to treat primary progressive MS — ocrelizumab (Ocrevus®), which is also approved for RRMS.2

The choice of disease-modifying treatment will depend on individual characteristics, such as disease stage, other health issues, and response to previous treatments. Some disease-modifying treatments are taken orally while others are in the form of injection or infusion.1 Each therapy can cause a number of side effects, some of which can be serious. 

Some of the most commonly prescribed disease-modifying treatments for MS are interferon beta medications. Although their exact mechanism of action is not fully understood, it is thought that they act through several overlapping mechanisms.3 These include the down-regulation of the expression of major histocompatibility complex (MHC) class II on antigen-presenting cells, the induction of interleukin 10 (IL-10), the shift towards type 2 helper T lymphocyte response, and the blockage of metalloproteases and adhesion molecules, which inhibits the migration of T lymphocytes. Interferon beta medications that can be used to treat MS include interferon beta-1a (Avonex®, Plegridy®, and Rebif®) and interferon beta-1b (Betaseron® and Extavia® ).

Other disease-modifying treatments approved by the FDA for MS are alemtuzumab (Lemtrada®) cladribine (Mavenclad®), dimethyl fumarate (Tecfidera®), diroximel fumarate (VumerityTM), fingolimod (Gilenya®), glatiramer acetate (Copaxone®, Glatopa®), mitoxantrone (Novantrone®), monomethyl fumarate (BafiertamTM), natalizumab (Tysabri®), ofatumumab (Kesimpta®), ozanimod (Zeposia®), ponesimod (Ponvory®), siponimod (Mayzent®), and teriflunomide (Aubagio®).4

Treatments for Relapses

Multiple sclerosis relapses that are caused by inflammation in the brain and spinal cord, which damages the myelin sheath, can be treated with corticosteroids.5 Intravenous methylprednisolone (Solu-Medrol®) or oral prednisone may be prescribed to reduce inflammation. Corticosteroids can have serious side effects and their long-term use does not seem to have any benefits in slowing disease progression.

In cases where patients cannot tolerate corticosteroids, HP Acthar Gel®, which stimulates the adrenal cortex to secrete cortisol, corticosterone, and aldosterone may be an option.6 It has been approved by the FDA to treat relapses in adult patients with MS. The side effects of HP Acthar Gel are similar to those of corticosteroids and include fluid retention, alteration in glucose tolerance, high blood pressure, mood changes, increased appetite, and weight gain.7

Another option to treat relapses in patients who are not responding to corticosteroids, or in case of severe exacerbations, is plasmapheresis.8 Plasmapheresis is not effective as a disease-modifying treatment and the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology (AAN) recommends that it should not be offered to patients with chronic or secondary progressive MS, and that it should only be considered as a second-line treatment of exacerbations which are resistant to steroids in patients with relapsing forms of the disease.9

Treatments to Manage MS Symptoms

Patients with MS may need treatment to manage symptoms of the disease. Many treatments can be prescribed to manage bladder and bowel dysfunction, fatigue, insomnia, itching, spasticity, tremor, gait impairments, dizziness and vertigo, pain, emotional changes, anxiety and depression, and sexual problems.4 

Rehabilitation programs can help patients maintain or restore function and include physical therapy, occupational therapy, and speech therapy.10 These therapies aim to improve patients’ mobility and increase their independence in their daily lives at home and work through the use of stretching and strengthening exercises as well as aids and adaptations.

Experimental Treatments

There are several treatments currently under investigation that could potentially benefit patients with MS. These include the remyelinating therapy clemastine fumarate for the treatment of RRMS and masitinib, simvastatin, ibudilast, and lipoic acid for the treatment of progressive forms of the disease.11

Stem cell therapy is another emerging potential MS treatment that holds promise. However, the field of stem cell therapy is still in its infancy and more research is needed before it can be used in the clinic.12 Several ongoing clinical trials are testing the potential benefits of stem cell therapy in patients with MS. 

References

  1. Multiple sclerosis. Mayo Clinic. Accessed June 11, 2021.
  2. FDA approves new drug to treat multiple sclerosis. News release. US Food and Drug Administration; March 29, 2017.
  3. Jakimovski D, Kolb C, Ramanathan M, et al. Interferon β for multiple sclerosis. Cold Spring Harb Perspect Med. 2018;8(11):a032003. doi:10.1101/cshperspect.a032003
  4. Medications. National Multiple Sclerosis Society. Accessed June 11, 2021.
  5. Managing relapses. National Multiple Sclerosis Society. Accessed June 11, 2021.
  6. Kutz C. H.P. Acthar Gel (repository corticotropin injection) treatment of patients with multiple sclerosis and diabetes. Ther Adv Chronic Dis. 2016;7(4):190-197. doi:10.1177/2040622316644481
  7. H.P. Acthar Gel. Package insert. Questcor Pharmaceuticals; 2010. Accessed June 11, 2021.
  8. Plasmapheresis. National Multiple Sclerosis Society. Accessed June 11, 2021.
  9. Cortese I, Chaudhry V, So Y, et al. Evidence-based guideline update: plasmapheresis in neurologic disorders – report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology. 2011;18;76(3):294-300. doi:10.1212/WNL.0b013e318207b1f6
  10. Kubsik-Gidlewska A, Klimkiewicz P, Klimkiewicz Cantor RF, Cornblath DR, Rae-Grantet A. Rehabilitation in multiple sclerosis. Adv Clin Exp Med. 2017;26(4):709-715. doi:10.17219/acem/62329
  11. Treatments in development. MS Society of Canada. Accessed June 11, 2021.
  12. Cuascut FX, Hutton GJ. Stem cell-based therapies for multiple sclerosis: current perspectives. Biomedicines. 2019;7(2):26. doi:10.3390/biomedicines7020026

Reviewed by Kyle Habet, MD, on 7/1/2021.

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