Multiple Sclerosis (MS)

Medications for multiple sclerosis (MS) may be used:

• During a relapse, to make the attack shorter and less severe.
• Over a long period of time, to alter the natural course of the disease (disease-modifying therapy).
• To control specific symptoms as they occur.

Controlling a relapse

Medications can shorten a sudden relapse and help you recover more quickly. Temporary treatment with medications called corticosteroids is the most common treatment used to control a relapse. These medications have not been shown to affect the long-term course of the disease or to prevent disability.

Altering the course of MS using disease-modifying treatment

Strong evidence suggests that MS is caused by the immune system causing inflammation and attacking the myelin—the coating surrounding the nerve and nerve fibers. Medications that change the activity of the immune system can reduce the number and severity of attacks that damage the protective myelin.

Interferon beta (Avonex, Betaseron, and Rebif), glatiramer acetate (Copaxone), mitoxantrone (Novantrone), and natalizumab (Tysabri) are the only medications that have been approved for this purpose. For people with relapsing-remitting MS, these medications can reduce the number and severity of relapses and can result in fewer brain lesions. They may also delay disability in some people. Betaseron and Novantrone may delay disease progression in some people with secondary progressive MS.

Currently, there is no effective disease-modifying treatment for primary progressive MS.

Some people have only one episode of a neurological symptom such as optic neuritis, but MRI tests suggest they may have MS. This is known as a clinically isolated syndrome. Many of these people go on to develop MS over time. In some cases, doctors will prescribe interferon beta for people who have had a clinically isolated syndrome. These medicines, when taken early or even before you have been diagnosed with MS, may keep the disease from getting worse or make your time without disease longer.

Relieving symptoms

Treating specific symptoms can be effective, even if it does not stop the progression of the disease. Symptoms that can often be controlled or relieved with medication include:

• Fatigue. Medications to reduce fatigue or help you sleep better may include amantadine (Symmetrel) or fluoxetine (Prozac).
• Muscle stiffness (spasticity) and tremors. Medications that may reduce muscles spasms or stiffness include baclofen (Lioresal), tizanidine (Zanaflex), dantrolene (Dantrium), gabapentin (Neurontin), diazepam (Valium), or clonazepam (Klonopin). Sometimes a combination of these medications works best to reduce your muscle symptoms.
• Urinary problems and constipation. Medications used to reduce frequent urination may include propantheline (Pro-Banthine), oxybutynin (Ditropan), or tolterodine (Detrol). Medications sometimes used to relieve constipation include bulk agents such as psyllium (Metamucil) or daily use of laxatives.
• Pain and abnormal sensations. Depending on the severity of the pain, both prescription and nonprescription medications may be tried. Over-the-counter medications may include acetaminophen, ibuprofen, or naproxen sodium. Prescription medications commonly used to reduce pain associated with MS include baclofen (Lioresal), carbamazepine (Tegretol), or gabapentin (Neurontin).
• Depression. Antidepressant medications may be used to reduce depression that often occurs as a result of having MS. Antidepressants often tried include tricyclic antidepressants—such as amitriptyline (Elavil), desipramine (Norpramin), or imipramine (Tofranil)—or selective serotonin reuptake inhibitors (SSRIs)—such as fluoxetine (Prozac) or sertraline (Zoloft) among others.
• Sexual difficulties. Medications used to relieve sexual difficulties that can be associated with MS include sildenafil (Viagra) for both men and women. Yohimbine and clomipramine may also be given to improve erectile dysfunction.

MS can affect many parts of the nervous system and produce a wide range of symptoms. The choice of medications depends on your symptoms. Medication may be used only some of the time or regularly, depending on how severe or constant a particular symptom is. Changes in diet, schedule, exercise, and other habits can also help manage some of these symptoms. See the Home Treatment section of this topic.

Medication Choices

Controlling a relapse

Medications used to treat an attack of multiple sclerosis (MS) and help you recover more quickly from a relapse include:

• Corticosteroids (such as methylprednisolone).
• Intravenous immunoglobulin (IVIG).
• ACTH (adrenocorticotropic hormone).
• Plasma exchange.

Relapsing-remitting MS

Medications used specifically for relapsing-remitting MS to reduce the number and severity of relapses and possibly delay disability include:

• Interferon beta (Avonex, Betaseron, and Rebif).
• Glatiramer acetate (Copaxone).
• Mitoxantrone (Novantrone) for relapsing-remitting MS that is rapidly getting worse or when other medicines for MS have not worked.
• Natalizumab (Tysabri). This drug is now available, on a limited basis, for treating relapsing forms of MS when other medicines for MS have not worked. Talk to your doctor to learn more about natalizumab.

Secondary-progressive MS

Medications used to treat and possibly delay the progression of secondary progressive MS that is also relapsing include:

• Interferon beta-1b (such as Betaseron).
• Mitoxantrone (Novantrone).

Primary-progressive MS

No medicines have been clearly proven to help, and none have been approved for primary-progressive MS. Some of the newer and experimental medications, such as immunosuppressants and other medications and biological chemicals (derived from or identical to substances produced by the body) are being tested for primary-progressive MS.

Medications being studied

A variety of immunosuppressants and other medications and biological chemicals (derived from or identical to substances produced by the body) have been tried as therapy for MS. While none have been clearly proven beneficial and none have been approved for treatment of MS, these medications may be used when standard therapy fails.

Several medicines are currently being tested in clinical trials. People with MS who have not responded to standard therapy sometimes choose to participate in these trials. To learn more about clinical trials, talk to your doctor or contact the National Multiple Sclerosis Society at www.nationalmssociety.org.

What To Think About

Long-term treatment with interferon beta and glatiramer acetate can improve the quality of life for some people who have relapsing-remitting MS by making relapses less frequent and less severe. Some evidence suggests that these medications may also reduce or delay future disability caused by this form of the disease.

The National Multiple Sclerosis Society recommends that people with a definite diagnosis of MS and active, relapsing disease start treatment with interferon beta or glatiramer acetate. Most neurologists support this recommendation and now agree that permanent damage to the nervous system may occur early on, even while symptoms are still quite mild. Early treatment may help prevent or delay some of this damage. In general, treatment is recommended until it no longer provides a clear benefit.

The National MS Society also says that treatment with medicine may be considered after the first attack in some people who are at a high risk for MS (before MS is definitely diagnosed).⁹

Despite the recommendation, however, some people find it difficult to decide whether to begin disease-modifying therapy, especially when their symptoms have been fairly mild. Some may not want to bear the risks and flu-like side effects of interferon therapy when they are not sure they need it. Some may want to see whether their disease worsens before starting therapy. A small percentage of people diagnosed with MS may never have more than a few mild episodes and may never develop any disability, but the disease is unpredictable. For more information, see:

Should I have disease-modifying therapy for MS?

If you decide not to try disease-modifying therapy at this time, work with your doctor to monitor your health through regular checkups and periodic MRI scans to evaluate whether the disease is progressing. If new lesions are developing or existing lesions are growing, you may want to reconsider your decision and begin treatment.

Treating symptoms and relapses

The need and desire for medication vary. If your symptoms are mild, you may choose to manage them without any medication. If you have specific symptoms that are causing problems, certain medications may help you keep them under control. Or you may want to use medication only during a relapse.

You may also want to consider:

• The possible side effects of using steroids or other medications to treat symptoms or control a relapse. Some people have only minor side effects, but others may have side effects that concern them more than their MS symptoms.
• The costs of treating symptoms and controlling relapses. In some cases, using medication to control symptoms and relapses may reduce the need for hospital stays.
• Other personal issues that you face at work or at home.

Also keep in mind that it can be hard to tell whether medication is helping. Multiple sclerosis is a disease with spontaneous remissions, which means that your condition can improve on its own, without any treatment. Just because your symptoms improve after treatment does not mean that a treatment is working.