Multiple Sclerosis Treatment

Treatment of multiple sclerosis (MS) is a long-term process. It is a complex condition so accessing comprehensive, multidisciplinary care is key to successful treatment and improving quality of life.

A team of specialists will work together to ensure the disease and its symptoms are managed as effectively as possible. Each team member, including a neuro rehabilitation physician, physiotherapist, occupational therapist, nutritionist, psychologist, gastroenterologist, speech and swallow therapists, and more, will provide unique insights into ways to modify the course of the disease, treat the symptoms, address relapses and psychological factors.

While there is no cure for MS, many types of treatment are available that can slow or prevent attacks from occurring, and delay or hopefully stop progression of the disease. Treatment can also help to manage symptoms and speed-up recovery following a relapse.

Medication Therapy

Treatment for MS typically involves medication therapy, which can be divided into two main types:

Treatment for an attack or relapse:

When a new symptom develops, which is significant and disabling (and if this is confirmed as a relapse due to new inflammation), corticosteroid (cortisone) is given intravenously for 5 -7 days. Steroids can only be given for a short duration, as long-term use may cause side effects.

Occasionally steroids alone are insufficient, and a plasma exchange-procedure is given, where the blood is cleaned of inflammatory substances, like a dialysis.

Disease modifying therapy (DMT):

These are medications that treat the disease itself. There are about 15 types of such medication. Depending on the individual’s specific diagnosis, caregivers offer the latest approved therapies to patients, which may be given as tablets, injections, or infusion (intravenous) medications. Infusion therapies, which can slow down the development of MS and reduce the number of flare-ups, are delivered on an outpatient basis at the Cleveland Clinic Abu Dhabi Infusion Center.

Intravenous drugs

Natalizumab

Natalizumab is given intravenously as an infusion in the hospital once a month, to reduce the number and severity of relapses.

It acts by preventing white blood cells from passing from the blood into the central nervous system where they can attack and cause damage to the nerves. It reduces inflammation by 80%.

While treatment with natalizumab is beneficial, there are possible side effects. Patients with the JC Virus are not recommended to take the medication as the risk of developing an illness called progressive multifocal leukoencephalopathy (PML) is increased. This is a rare but fatal brain infection. When your immune system is weakened and your body is less able to fight infections, the JC virus can become active and cause inflammation and damage to the brain. A routine blood test is done to detect the JC virus and provide an indication of the risk that you might develop PML.

There is also an increased risk of developing infections, and a risk of liver damage when taking natalizumab. Routine blood tests are done to monitor these levels. Commonly reported side effects of natalizumab include dizziness, nausea, urticaria (a skin rash) and stiffness.

Ocrelizumab

Ocrelizumab is given intravenously as an infusion in the hospital. The first dose is given as two separate infusions, two weeks apart. Then the medication is given once every 6 months. This medication is given to treat active relapsing remitting, and very active relapsing remitting MS. Ocrelizumab acts by killing B cells, which are a type of white blood cell (lymphocyte). These cells are involved when the immune system attacks nerve cells. The targeted B cells are then destroyed.

The possible side effects associated with ocrelizumab include, but not limited to, flu-like symptoms, weakness, muscle aches, tiredness, dizziness, headaches, allergic reactions, breathlessness, painful mouth sores, ulcers, blisters on skin, abnormal blood counts causing anemia, and bleeding. There is a small risk of progressive multifocal leukoencephalopathy (PML) which is a rare but fatal viral brain infection. Routine blood tests are completed while taking ocrelizumab.

Alemtuzumab

Alemtuzumab is given intravenously as an infusion in the hospital in two treatment courses, twelve months apart. It is given to treat very active relapsing remitting MS and reduces the number of relapses by over two thirds (70%). Alemtuzumab is a monoclonal antibody that targets and kills immune cells. It binds to a marker, CD52, on the lymphocytes or white blood cells, and kills them.

You cannot take this treatment if you have an immune deficiency, including HIV, suffer from allergic reactions, or if you are pregnant. There is a risk of hypothyroidism, bleeding, and a risk of serious infections. Monthly blood and urine checks will be performed due to the serious nature of the side effects, as well as checks every 3 months for thyroid function, and annual cervical smear tests. Patients should not receive any live vaccines for the rest of their life as it reduces the body’s ability to develop immunity. More recently there has been concern that this drug may increase the risk of strokes.

Rituximab

Rituximab is given intravenously as an infusion in the hospital. This medication depletes the B-white blood cells.

Common side effects associated with rituximab include flu-like symptoms, weakness, muscle aches, tiredness, dizziness, headaches, allergic reactions, breathlessness, painful mouth sores, ulcers, blisters on skin, abnormal blood counts causing anemia, bleeding, risk of serious infections, and death. There is a small risk of progressive multifocal leukoencephalopathy (PML) which is a rare but fatal viral brain infection. Routine blood tests are completed while taking rituximab to monitor your condition carefully.

Subcutaneous Injections

Ofatumumab

Ofatumumab is a self-administered subcutaneous injection that comes in pre-filled syringes. It is given for the treatment of relapsing remitting MS. Ofatumumab works by attacking specific targets in the immune system. It binds to a marker on the surface of B lymphocytes and destroys them, so that they cannot attack nerve cells.

Common side effects are injection-related reactions. Other side effects that affect at least 10% of people taking ofatumumab, include head colds, headache, chest infections, and urinary tract infections. Routine blood tests are given to people taking this medication to monitor for any side effects.

Interferon beta 1a

Interferon beta 1a is a self-administered subcutaneous injection that comes in pre-filled syringes, and is for relapsing remitting MS. It is given once every three weeks. It can also reduce the number of brain lesions on MRI and reduce the risk of worsening disability.

Interferon beta 1a works by reducing both inflammation and the immune response that is attacking the body’s own nerve cells. Routine blood monitoring is given to anyone taking this medication. Common side effects include flu-like symptoms and myalgia (muscle pain), but these are transient and should improve spontaneously in most people. Prophylactic paracetamol or ibuprofen (unless contraindicated) can be used to relieve these side effects. Injection site reactions can occur, but alternating injection sites will reduce this.

Peginterferon beta 1a

Peginterferon beta 1a is a self-administered subcutaneous injection that comes in pre-filled syringes, given once every two weeks. It is used to treat relapsing remitting MS. Peginterferon beta 1a works by reducing both inflammation and the immune response that is attacking the body’s nerve cells. Routine blood monitoring is offered to anyone taking this medication. Common side effects include flu-like symptoms and myalgia (muscle pain), but these are transient and should improve spontaneously in most people. Prophylactic paracetamol or ibuprofen can be used to relieve these side effects. Injection site reactions can occur, but alternating injection sites will reduce this.

Interferon beta 1a

Interferon beta 1a is a self-administered subcutaneous injection given once a week. It is given to treat relapsing remitting MS. Interferon beta 1a works by reducing inflammation and the immune response that is attacking the body. Common side effects include flu-like symptoms and myalgia (muscle pain), but these are transient and should improve spontaneously in most people. Prophylactic paracetamol or ibuprofen can be used to relieve these side effects. Injection site reactions can occur, but alternating injection sites will reduce this.

Glatiramer acetate

Glatiramer acetate is a once a day, self-administered subcutaneous injection that comes in pre-filled syringes. It is given to treat relapsing remitting MS. Glatiramer acetate works by diverting an immune attack away from the myelin on nerve cells. Routine blood monitoring is given. Common side effects include flu-like symptoms and myalgia (muscle pain), but these are transient and should improve spontaneously in most people. Prophylactic paracetamol or ibuprofen can be used to relieve these side effects. Injection site reactions can occur, but alternating injection sites will reduce this.

Tablets

Fingolimod

Fingolimod is a tablet taken once a day for relapsing remitting MS. Fingolimod acts by binding to certain white blood cells (lymphocytes), so they become trapped in the lymph nodes. This prevents them from crossing into the central nervous system (CNS), which helps to reduce inflammation and stops them from damaging nerve cells.

Common side effects include an increased risk of infections, cough, headache, back pain, and diarrhea. Contra-indications to using this medication are immunosuppression, active infection, and active malignancies (except cutaneous basal cell carcinoma).

Fingolimod can slow the heart rate after the first dose, so it is to be avoided in those with cardiovascular problems. An ECG test is completed prior to starting on Fingolimod. Progressive multifocal leukoencephalopathy (PML), an uncommon and serious brain viral infection, has been described in a handful of cases. Less common side-effects include the risk of macular oedema, so an eye examination will be completed before starting treatment. Liver enzymes can increase, and white blood counts can drop, so levels will be monitored every 3 months.

Dimethyl fumarate

Dimethyl fumarate is a tablet taken twice daily to treat relapsing remitting MS. Dimethyl fumarate works by reducing the inflammation in an immune response and protects nerve cells from damage. Common side effects include flushing, diarrhea, nausea, abdominal pain, and headache. Taking dimethyl fumarate with food may reduce the incidence of flushing.

White blood cell counts can fall, so need to be monitored every 3 months. There is a small risk of progressive multifocal leukoencephalopathy (PML), which is a rare but fatal viral brain infection.

Cladribine

Cladribine is taken as a tablet for very active relapsing remitting MS. It is taken in two treatment courses, twelve months apart. Cladribine works by slowly reducing the numbers of T and B lymphocytes (white blood cells that cause the damage associated with MS). Side effects can include a reduced white blood cell count (lymphopenia) and herpes (oral herpes and shingles). Prior to starting treatment with cladribine, baseline blood tests are done and then repeated every 3 months.

Siponimod

Siponimod is a tablet given to treat secondary progressive MS. It is taken once a day. It also reduces the frequency of relapse. Siponimod works by binding to and trapping the lymphocytes (white blood cells) in the lymph glands. This reduces the number of lymphocytes in the blood from reaching the brain, and therefore reducing attacks on nerve cells in the brain and spinal cord.

The side effects of siponimod include low white blood cell count, increased liver enzyme levels, slower heart rate when starting treatment, macular oedema (swelling in the back of the eye affecting vision), high blood pressure, shingles, and convulsions. An ECG test along with an eye exam will be completed prior to starting on siponimod. As liver enzymes can rise and white blood counts can drop, your levels will be monitored every 3 months.

Teriflunomide

Teriflunomide is a tablet taken to treat relapsing remitting MS. It is taken once a day . Teriflunomide works by reducing the number of white blood cells (B-cells and T-cells) that cause damage to nerve cells seen in MS. Common side effects include feeling sick, diarrhoea, and hair thinning, which can occur during the first few months of treatment but generally later improve. Increased blood levels of liver enzymes can also occur, so levels will be monitored every 3 months.

Symptomatic Therapy

This includes a range of medications used to manage symptoms of MS, including pain, spasticity (muscle stiffness), urinary urgency or frequency, muscle spasms, and fatigue. Various options, including Botox injections, may be offered.

Rehabilitation

Some patients have incomplete recovery from attacks or develop progressive difficulties that will need help from physical therapists or occupational therapists. Neuro rehabilitation consultants can supervise and assist with more complex neuro-rehabilitation needs.

Patients are offered a tailored treatment plan, which can include physiotherapy, occupational therapy, and rehabilitation, that helps improve or maintain functions effectively. They also focus on overall fitness and address things such as mobility.

Emotional support

Addressing emotional health is an important part of comprehensive care. Everyone copes with various life stressors in different ways, and while some may deal with it very well without any help from professionals, some may find it extremely difficult. It can therefore be helpful to meet with a psychologist to develop coping strategies, and who can also provide nonmedical treatments for depression and anxiety. Occasionally, patients develop other cognitive issues associated with MS. A psychologist can support with this.