Multiple sclerosis (MS) is an autoimmune disorder which affects the brain and spinal cord, causing memory, speech, and sight problems and impairing balance and bowel function. The disease is brought on by the immune system attacking the protective shell that coats nerve fibers in the brain and spinal cord, causing communication issues between the brain and the body. MS can be physically debilitating, with some patients ultimately having issues with mobility and needing to use a cane or walker, as well as mentally debilitating –many MS sufferers experience mood swings, forgetfulness, and/or depression.
Symptoms of MS may include:
- Numbness or weakness in one or more limbs that typically occurs on one side of your body at a time, or the legs and trunk
- Electric-shock sensations that occur with certain neck movements, especially bending the neck forward
- Tremor, lack of coordination, or unsteady gait
- Slurred speech
- Tingling or pain in parts of your body
- Problems with sexual, bowel, and bladder function
Vision issues can also occur, such as:
- Partial or complete loss of vision, usually in one eye at a time, often with pain during eye movement
- Prolonged double vision
- Blurry vision
Fortunately, MS is now a treatable disease, and many patients have mild symptoms requiring only intermittent treatment for decades following diagnosis. Some patients, however, may have more frequent bouts of MS “attacks,” also called “flares” or “relapses,” in which their symptoms suddenly worsen. These events may last a few days, weeks, or even months.
Medications for MS attacks
Medication is available to curb the frequency and severity of MS attacks. Common drugs administered for MS include corticosteroids, which reduce inflammation throughout the body, including the nerves. Corticosteroids may come with a number of side effects, including insomnia, elevated blood pressure, or mood swings. Another short-term treatment for MS attacks (primarily used when steroids fail) is called plasma exchange, or plasmapheresis, which involves removing part of your blood cells, mixing them with a protein solution and then reinjecting them into your body.
Both active and non-active SPMS may be treated with several different medications (which are also available for RRMS) such as dimethyl fumarate, natalizumab and teriflunomide, although more than a dozen treatments are approved by the FDA to manage the disease. One new medication currently being studied in clinical trials is called masitinib, an oral immunomodulatory drug which shows promise in treating both SPMS and PPMS (detailed below.) The drug is making its way to Phase 3 clinical trials and could be a potential game-changer for MS sufferers.
Treatments for Primary Progressive MS (PPMS)
Primary progressive MS, also known as PPMS, is a type of multiple sclerosis that continues to worsen with time, resulting in increased severity of symptoms over the course of the sufferer’s life. Those with PPMS, like those with other types of MS, may have periods where their symptoms appear to become more stable, although these intervals are usually brief.
PPMS is treatable, however. One medication approved by the FDA to treat the disease exists, called ocrelizumab (brand name OCREVUS). Ocrelizumab is taken twice a year, and can help MS patients reduce their frequency of relapses by about 70%. The drug is considered very effective for treating different types of MS, but it does come with side effects, which may include increased risk of infections, trouble breathing, fever, nausea, headache and more. In addition, ocrelizumab can cause an allergic reaction in some people. Besides ocrelizumab, there are no other FDA-approved treatments on the market.
Treatments for Relapsing-Remitting MS (RRMS)
More than a dozen medication options are available to prevent or modify the disease course (so called “disease modifying therapies”) in patients with relapsing-remitting multiple sclerosis (RRMS). These include injected drugs, such as beta interferons and glatiramer acetate, as well as a handful of infused medications, including natalizumab, ocrelizumab, and alemtuzumab. Oral MS treatments have also proliferated over the last decade, and now include fingolimod, dimethyl fumarate, teriflunomide, and siponimod. The most recent FDA approvals in this category were made in March and April 2020 for ozanimod and monomethyl fumarate, respectively. Determining which of these treatments an individual patient is most likely to respond to, and which they are most likely to experience side effects from, continues to be a complex process with ample room for improvement. Fortunately, some of the most recent entrants to the multiple sclerosis treatment arena have improved safety profiles (less frequent or severe side effects and fewer adverse events).
Treatments for Secondary Progressive MS (SPMS)
Secondary progressive MS, also known as SPMS, is a type of multiple sclerosis that is commonly diagnosed in people who already have another type of MS, usually RRMS. SPMS is categorized by the patient no longer showing any signs of disease remission, meaning the condition does not respond to treatment and continues to worsen. Before RRMS turns into SPMS, the patient may experience gradually worsening symptoms of RRMS which include changes in vision, bladder control problems, difficulties walking, and fatigue. These symptoms can also manifest themselves in the form of a relapse, which may last from a few hours to multiple days. Once these relapses become more and more frequent, they often become a constant affliction, at which point the patient’s MS is categorized as “non-active” SPMS. Those who still experience relapses are considered to have “active” SPMS.
A Rich Pipeline
Besides the drugs mentioned above, there are a few experimental MS treatments currently being used in clinical trials. One of these medications is called ofatumumab, used for treating different forms of relapsing MS. The drug works similarly to ocrelizumab, by reducing inflammation in the brain and spinal cord, and if approved by the FDA, will be taken by MS patients once a month, subcutaneously. When tested in a clinical trial, patients administered ofatumumab had a 90% reduction in active brain lesions, proving that the drug could effectively decrease inflammation in the body.
Another experimental drug making its way to Phase 3 clinical trials is called ublituximab, developed by TG Therapeutics. Ublituximab is also used to treat relapsing MS, and works by targeting receptors on a certain antigen (CD-20) found on B-cells, leading to a reduction of the cells in the blood. The drug is also being studied for its potential in treating other autoimmune diseases like lupus and rheumatoid arthritis. Patients who received the medication in a clinical trial had a 99% reduction in B-cells, with no serious side effects. Once ublituximab makes its way to the market, it could be very beneficial for MS patients.
Finally, a third medication, a BTK inhibitor which is the subject of multiple trials, could be another potentially effective MS treatment. Called evobutinib and developed by Merck KGaA, the drug is in varying stages of several Phase 3 clinical trials, and its efficiency is being compared with existing MS medications. In one study, patients who received evobutinib rather than another medication or a placebo had both reduced brain lesions and significantly fewer relapses. The drug, like ublituximab, is also being studied for its use in managing other autoimmune conditions.
All of the above treatments are very exciting developments for those with MS, and, assuming their promising results thus far are confirmed in ongoing trials, we’ll hopefully see them approved by the FDA and available for patients in pharmacies as soon as possible.
Other treatments for management of MS
- Physical therapy. Working with a physical therapist can get you adjusted to living with MS and help you perform day-to-day tasks with less difficulty.
- Muscle relaxants. Many MS sufferers experience painful muscle spasms. Muscle relaxants such as baclofen and tizanidine are often prescribed to ease muscle pain.
- Stimulants. A large number of people living with MS often find themselves fatigued. Doctors can prescribe amantadine, modafinil, or methylphenidate to reduce fatigue caused by MS.
If you have MS and are considering a new treatment option, the above list may help you understand and explore your current and upcoming options.
Surya Singh, MD
Founding Medical Partner
Dr. Singh is actively licensed & board certified in internal medicine. He is currently the CEO of gWell, Inc, a genomics and wellness focused digital health company, and serves as a senior advisor and board member for mission aligned companies and non-profits. In addition, he is an Adjunct Instructor of Medicine at Harvard Medical School. He was formerly Corporate Vice-President and Chief Medical Officer of Specialty Pharmacy at CVS Health, and was an attending physician for many years at the Brigham and Women’s Hospital in Boston.