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The past two decades have seen great leaps forward in the treatment of multiple sclerosis, a progressive disease in which the immune system attacks the central nervous system. While multiple sclerosis still cannot be cured, medical science now houses an arsenal of disease-modifying drugs that can reduce attacks and hold off disability for years or decades.
What is multiple sclerosis?
Multiple sclerosis (MS) is a chronic autoimmune disease in which the immune system targets the central nervous system (CNS). During MS attacks, a component of one’s immune system known as white blood cells damage the nerves in the brain, spine, and optic nerve.
In particular, the immune system targets the myelin sheath, a protein and fat coating that surrounds every nerve cell. As the myelin sheath around nerves deteriorates, the nerves lose their ability to seamlessly conduct electrical signals along their branches. Each attack produces new lesions and the cumulative damage results in progressively worsening complications and disabilities.
MS is diagnosed as one of four types:
- 70 to 80% of MS patients have relapsing-remitting multiple sclerosis, or RRMS. Attacks are followed by periods of partial or complete stability and remission that can last months or years.
- Many patients with RRMS will eventually develop secondary progressive multiple sclerosis (SPMS). The condition will progress rapidly with few if any remissions after an initial relapsing-remitting course.
- 20% of MS patients have primary progressive multiple sclerosis (PPMS). From the initial onset of symptoms, the disease progresses without stable periods of remission.
- Some MS patients (about 5%) have progressive-relapsing MS (PRMS), a form of primary progressive MS with occasional relapses.
- Clinically isolated syndrome (CIS), a single demyelinating episode caused by the immune system.
- Fulminant MS is a rapidly progressing, severe form of relapsing-remitting MS that can lead to death in a few weeks after the onset of an attack, and
- Benign MS, a form of relapsing-remitting MS, in which very mild and even asymptomatic attacks are followed by long periods of remission.
Every relapse causes a diverse range of neurological symptoms depending on which part of the brain or spine is damaged by the attack. Over time, damage accumulates into worsening complications and disabilities such as:
- Impaired mobility
- Fatigue
- Weakness
- Tremor
- Muscle spasms
- Vision problems
- Vertigo
- Balance and coordination problems
- Slurring or slowing of speech
- Cognitive impairment
- Mood disorders
- Difficulty swallowing
- Hearing loss
- Facial pain
- Bladder dysfunction
- Constipation
- Erectile dysfunction
Approximately 400,000 people in the United States are living with MS. Most experience their first symptom flare-ups between the ages of 20 and 40, but the disease could start earlier or later.
How is multiple sclerosis diagnosed?
Diagnosis of multiple sclerosis is based on a thorough medical history and physical exam, imaging the central nervous system, measuring sensory stimulation response, and measuring antibodies in the spinal fluid and blood.
A medical history and physical will help determine symptoms as well as a previous history of exacerbations. Because MS affects many areas of the central nervous system, MS symptoms can vary widely between patients, including vision, hearing, balance, muscle, coordination, movement, speech, sensory, cognitive, and psychiatric problems. For a definitive diagnosis, the physician must establish at least two flare-ups.
Magnetic resonance imaging, or MRI, is the standard for identifying nerve damage in the brain, spinal cord, and optic nerve due to MS. For a definitive diagnosis, the physician must find at least two areas of the central nervous system damaged by the immune system.
A spinal tap will be performed to measure antibodies in the cerebrospinal fluid (CSF). A needle is inserted between two vertebrae in the lower back to remove the fluid. This fluid will be tested for antibodies that are typically found in patients with multiple sclerosis.
Finally, a neurologist will measure “evoked potentials.” This test measures brain waves to figure out how quickly and how strongly nerves respond to sensory stimulation, such as seeing an object, hearing a sound, or having an electrical shock applied to the arms or legs.
Multiple sclerosis treatment options
Multiple sclerosis is not curable. Treatment consists of preventing relapses, reducing the effects of exacerbations, and rebuilding function during stable periods.
MS treatment begins almost immediately upon diagnosis. The short-term treatment goal is to reduce nerve damage. The long-term goal is to prevent the disease from advancing to secondary progressive MS and to minimize impairment.
MS treatment has three components: disease-modifying therapies (DMTs) that prevent exacerbations and decrease the risk of nerve damage, exacerbation therapies that rapidly suppress the immune system to prevent injury during a flare-up, and symptomatic therapies help to manage symptoms as well as regain physical and mental functioning during stable periods.
While MS is primarily treated by a neurologist, the disease causes a wide range of complications. The treatment team will probably also include a urologist, gastroenterologist, an ophthalmologist, or a psychiatrist to treat complications.
Disease-modifying therapies
Disease-modifying therapies (DMTs) are the central pillar in treating relapsing-remitting MS. These medications are generally started very early on after diagnosis since research has demonstrated their ability to prevent permanent damage in the central nervous system. They also are able to prevent the severity and frequency of flare-ups, reduce the development of new areas of damage in the brain and spinal cord, and overall reduce accumulation of disability.
Exacerbation treatment
Severe exacerbations or flare-ups are treated with injectable and oral corticosteroids to reduce inflammation of involved nerves. While steroids won’t provide any long term benefit in the management of MS, the goal of their use in flare-ups is to recover more quickly which in turn limits damage. If steroids don’t work or can’t be used, a doctor may turn to plasma exchange, or plasmapheresis. Plasma exchange removes blood, separates the cells from the plasma where high levels of antibodies are contained in autoimmune diseases, then re-infuses only the cells and replaces the plasma in the form of saline and/or albumin.
Symptomatic therapies
Medications: Complications such as walking impairment, fatigue, tremor, muscle spasms, bladder dysfunction, bowel dysfunction, pain, and mood disorders will be managed with appropriate medications.
Rehabilitative therapy: Rehabilitative therapy—physical therapy, occupational therapy, cognitive remediation, and speech/language therapy—is a cornerstone of MS treatment. Rehabilitation helps to regain physical, neurological, speech, and cognitive functions after an exacerbation and improve functioning during stable periods. Safe mobility, proper use of assistive devices, daily routine performance, and increasing strength, muscle use, balance, and coordination are primary treatment goals.
Assistive devices: Safe mobility and performance of daily functions for some patients will require assistive devices. Braces, functional electrical stimulation (FES), canes, walkers, wheelchairs, and scooters may become necessary for mobility as disability progresses. Wrist weights, weighted or modified utensils, plate guards, and other weighted objects can help maintain daily routines in patients with tremor or spasticity. Voice amplifiers can help with speech problems. Finally, a wide range of smartphone apps can help with cognitive problems such as memory, attention, and managing daily activities.
Surgery: Surgery is only considered when complications cannot be managed through medicine or physical therapy. Surgical options include rhizotomy and deep nerve stimulation. A rhizotomy involves cutting nerves to reduce either pain or muscle spasms. Deep nerve stimulation involves implanting electrodes in the brain attached to a medical device and applying low-level shocks to reduce tremors.
Emerging therapies
Much of the current emerging therapies involve drugs that limit or reverse the damage of MS exacerbations.
Ibudilast, simvastatin, biotin (vitamin B7), and lipoic acid are all being investigated as drugs that either minimize damage (biotin and lipoic acid) or protect nerve cells from damage (ibudilast and simvastatin).
Some monoclonal antibodies are in clinical trials as remyelinating agents, that is, as substances that can promote the healing of nerve cells damaged by the immune system.
Finally, human trials are currently underway involving stem cell therapy in which the immune system is destroyed and replaced by stem cells that will grow a new immune system that doesn’t attack brain cells.
Multiple sclerosis medications
Medications either prevent or minimize relapses (disease-modifying therapies), rapidly suppress the immune system during a flare-up (corticosteroids), or improve symptoms. Most disease-modifying medications effectively treat relapsing forms of MS but are less effective against progressive forms.
Glatiramer
Glatiramer acetate is the first-line treatment for relapsing-remitting MS. The drug reduces the relapse rate and inflammation during a flare-up. For this reason, glatiramer may slow disease progression. While its exact mechanism is not understood, it is believed to block the myelin damaging immune attack in a flare-up.
Beta interferons
Another first-line treatment for relapsing-remitting MS, beta interferons are naturally-occurring proteins designed to shut down an immune response. Avonex, Betaseron, Extavia, Plegridy, and Rebif have all been shown to reduce relapses counts, MRI activity, and lesion accumulation.
Monoclonal antibodies
Some of the most effective second-line drugs for relapsing-remitting MS are monoclonal antibodies, proteins similar to the proteins the body uses to identify foreign substances in the body. Natalizumab, Ocrevus (ocrelizumab), Rituxan (rituximab), and Lemtrada (alemtuzumab) all interfere with the immune system cells (B cells and T cells) and prevent immune cells from crossing the blood-brain barrier. Monoclonal antibodies are typically administered as infusions with varying frequencies.
Immunosuppressants
Immunosuppressants work by weakening the immune system - which in an autoimmune disease such as MS helps suppress the attack on the body’s own immune system. Immunosuppressants for MS include Gilenya (fingolimod), Mayzent (siponimod), Aubagio (teriflunomide), Tecfidera (dimethyl fumarate), cladribine, and mitoxantrone.
Corticosteroids
For an active MS flare-up, high doses of intravenous corticosteroids are used to rapidly de-escalate the immune response. Corticosteroids rapidly suppress the immune system, reduce inflammation, and prevent white blood cells from crossing the blood-brain barrier into the central nervous system.
At the onset of symptoms, corticosteroids such as methylprednisolone or dexamethasone are injected daily for severaldays, sometimes followed by oral steroids for an additionl seven to 14 days. For patients unable to tolerate corticosteroids, a doctor may use HP Acthar Gel, which steadily releases a hormone, ACTH, that stimulates the body’s production of corticosteroids.
Symptom relief medications
Symptom relief or complications medications aim to reduce impairment caused by MS. The only symptom relief medication approved by the FDA for MS is dalfampridine, used to improve MS patients’ ability to walk. Taken as a tablet, dalfampridine improves nerve conduction and can produce faster walking speeds in MS patients.
Fatigue, experienced by 80% of MS patients, may be treated by off-label amantadine (dopamine agonist), modafinil (a wakefulness agent), or methylphenidate (a stimulant). Tremor, experienced by 70% of MS patients, is often treated with benzodiazepines (a type of sedative), anticonvulsants, or beta-blockers. Spasticity is usually treated with off-label baclofen, but tizanidine, dantrolene, gabapentin, or cannabinoids might be prescribed. Other complications, such as bladder dysfunction or mood disorders, will be treated by appropriate medications. Currently, there are no proven drug treatments to improve cognitive impairment due to MS.
What is the best medication for multiple sclerosis?
Multiple sclerosis is a complex and unpredictable condition. Treatment is founded on disease-modifying medicines which can have serious side effects. Some patients may not be able to take the most effective medicines or show any improvement. For all these reasons, the “best” medication for any patient will reduce the incidence of relapses while not causing intolerable side effects.
| Best medications for multiple sclerosis | ||||
|---|---|---|---|---|
| Drug Name | Drug Class | Administration Route | Standard Dosage | Common Side Effects |
| Copaxone (glatiramer acetate) | Immunomodulator | Injection | 40 mg injected subcutaneously three times per week | Injection site reactions, rash, chest pain |
| Rebif (interferon beta 1a) | Immunomodulator | Injection | 22 mcg or 44 mcg injected subcutaneously three times per week | Flu-like symptoms, abdominal pain, depression |
| Tysabri (natalizumab) | Monoclonal antibody | Injection | 300 mg infused intravenously over one hour every four weeks | Headache, fatigue, nausea |
| Ocrevus (ocrelizumab) | Monoclonal antibody | Injection | 300 mg infused intravenously over 2.5 hours every 2 weeks for 2 infusions, then 600 mg infused intravenously over 3.5 hours every 6 months | Infections,infusion reactions, depression |
| Gilenya (fingolimod) | Immunosuppressant | Oral | 0.5 mg taken by mouth once daily (if weight less than or equal to 40 kg, dose reduced to 0.25 mg by mouth once daily) | Headache, flu-like symptoms, diarrhea |
| Aubagio (teriflunomide) | Immunomodulator | Oral | 7 mg to 14 mg bytaken by mouth once daily | Headache, diarrhea, hair loss |
| Tecfidera (dimethyl fumarate) | Immunomodulator | Oral | 240 mg taken by mouth twice daily | Flushing, abdominal pain, diarrhea |
| Novantrone (mitoxantrone) | Anthracenedione | Injection | Dosage depends on weight, administered every 3 months as an intravenous infusion | Infections, hair loss, nausea |
| Solu-Medrol (methylprednisolone sodium succinate) | Corticosteroid | Injection | Dosage depends on weight, administered as an intravenous infusion once daily for 2 to 5 days | Nausea, heartburn, headache |
| Ampyra (dalfampridine) | Potassium channel blocker | Oral | 10 mg taken by mouth twice daily | Urinary tract infection, insomnia, dizziness |
Many of the standard dosages above are from the U.S. Food and Drug Administration (FDA). Dosage is determined by your doctor based on your medical condition, response to treatment, age, and weight. Other possible side effects exist. This is not a complete list.
What are the common side effects of multiple sclerosis medication?
Side effects from MS DMTs (disease-modifying therapies) are common and can be severe enough to interfere with treatment. Some medications come with boxed warnings about dangerous side effects and others are only available through strict Risk Evaluation and Mitigation Strategy (REMS) programs. For this reason, the greatest problem with MS drugs is patient compliance because of side effects.
Almost half of patients taking glatiramer acetate will experience side effects and about one in ten will experience significant side effects. Most aren’t serious and include headache, flushing, and injection site reactions. More serious but rare side effects involve organ problems.
Interferon-beta agents cause flu-like symptoms in three out of five patients. Injection site reactions are also very common. However, the most serious side effects of beta interferons are liver problems, thyroid disease, and low levels of white blood cells.
Like beta interferons, monoclonal antibodies commonly cause flu-like symptoms in the days following an infusion. Nausea, vomiting, diarrhea, and low blood pressure are also common. The most serious side effects are potentially hazardous allergic reactions that include anaphylaxis, a sudden and life-threatening drop in blood pressure.
Many immunosuppressants and immune modulator drugs used for MS were originally developed for cancer chemotherapy, so side effects include nausea, vomiting, and hair loss. These drugs can have severe side effects including heart problems.
All DMTs are immune-suppressing or immune-modulating drugs. They prevent flare-ups by weakening the immune system. For this reason, they all increase the risk of infection. The most serious possible infection is Progressive Multifocal Leukoencephalopathy (PML), a viral infection of white matter in the brain that can progress to severe debilitation or death. The only way to treat PML is to take the patient off the immune-suppressing medication.
Steroids rapidly suppress the immune system but they have several unpleasant and commonly-experienced side effects including mood and behavior changes, aggressiveness, increased appetite, weight gain, and high blood pressure.
Dalfampridine can cause headaches, dizziness, balance problems, and urinary tract infections. It can cause serious side effects, such as seizures, only when the recommended dose is exceeded.
What is the best home remedy for multiple sclerosis?
Multiple sclerosis is an unpredictable illness, so while some people report that home remedies, natural treatments, or diets may help their MS, there’s no way of knowing for sure.
Diet
There are many contradictory claims made for diets that can prevent MS relapses. However, research suggests that some nutrients may help reduce exacerbations, protect nerves during exacerbations, or help heal damaged nerves. These include biotin (vitamin B7), vitamin B12, vitamin D, and lipoic acid. Several studies have found deficiencies in these nutrients in MS patients.
Exercise
Regular, daily exercise helps reduce the severity of complications including mood, fatigue, cognitive function, and strength. Exercise should not be too wearing, however. Start slowly and take it easy. For people with balance or mobility issues, aquatic exercise allows movement that may not be possible on land.
Reflexology
Reflexology is a type of massage involving pressure put on certain places on the feet, hands, and ears. It has been shown to reduce tingling and prickling feelings (paresthesia) in MS patients.
Ginkgo biloba
Of the many dietary supplements touted for MS, ginkgo biloba has been objectively shown to reduce fatigue. This supplement is notorious for drug interactions, so use should be discussed thoroughly with a healthcare provider.
Frequently asked questions about multiple sclerosis
Are MS medications dangerous?
Patients frequently experience side effects with MS disease-modifying therapies (DMTs). Some side effects may be serious and even life-threatening. All DMTs reduce the body’s ability to fight off bacteria and viruses, so infection is a common problem. The good news is that the MS medical team closely monitors their patients for any problems they might have with the medications.
Is multiple sclerosis curable?
Multiple sclerosis is not curable.
Can multiple sclerosis be cured naturally?
Multiple sclerosis cannot be cured naturally.
Can MS be cured by diet?
Multiple sclerosis cannot be cured by diet.
How long can you live with multiple sclerosis?
Current disease-modifying therapies mean that people with multiple sclerosis live normal lifespans, about seven years less than average according to the National Multiple Sclerosis Society.
What vitamins are good for multiple sclerosis?
Vitamins that have been shown to reduce relapses, protect nerves from damage, or help heal damaged nerves include vitamin B7, vitamin B12, vitamin D3, and lipoic acid.
What happens to your body when you have MS?
Multiple sclerosis damages nerves in the central nervous system: the brain, the spinal cord, and the optic nerve. Multiple sclerosis attacks can affect any part of the central nervous system, so it can affect any part of the body. The most common complications are fatigue, weakness, mobility problems, tremor, muscle spasms, vision problems, balance problems, coordination problems, and speech problems. Memory, attention, executive function, and mood are also affected.
What is the best medication for multiple sclerosis?
The central pillar of MS treatment is disease-modifying therapy that reduces the risk of relapses by weakening the immune system. The first-line DMTs are glatiramer acetate and beta interferons. Second-line therapies include monoclonal antibodies and immune suppressants.
What drugs are available for MS?
The past two decades have seen an explosion of medications that reduce the risk of relapses. These drugs interfere with or modulate the immune system and include glatiramer, beta interferons, monoclonal antibodies, and immunosuppressive drugs.
What foods to avoid if you have multiple sclerosis?
A healthy, well-balanced, and nutritious diet is the best diet for multiple sclerosis just as it is for the rest of the population. Consuming saturated fats, processed foods, junk foods, caffeine, and alcohol will produce health problems in people with or without MS, but these avoidable health problems are added on top of the burdens that MS patients have to bear.
Which drug class is the first-line treatment for multiple sclerosis?
The first-line treatments for multiple sclerosis are disease-modifying therapies (DMTs) that change or weaken the body’s immune system. Called immunomodulators, the first-line DMTs are glatiramer acetate and beta interferons such as Rebif, Betaseron, Avonex, Extavia, and Plegridy.
Which MS drug has the least side effects?
All MS disease-modifying therapies have commonly-experienced side effects that can sometimes be severe. Some medications like daclizumab have been pulled from the market because of safety concerns, others such as Gilenya, Tysabri, Lemtrada are available only under strict Risk Evaluation and Mitigation Strategies (REMS) programs, while others have serious boxed warnings about potentially severe side effects. In the end, side effects will vary from patient-to-patient. The good news is that MS treatment is very hands-on. The treatment team will closely monitor patients and stand guard over possible drug side effects.