The key to better outcomes for patients with MS is to address it early.
Multiple sclerosis (MS) disease diagnosis goes back to 1300s, when individuals with progressive symptoms started being discovered, observed, and reported.
In 1868, famous French neurologist Jean-Martin Charcot, MD, who lectured about MS and named the disease, is claimed by many to be the founder of modern neurology, and he inspired many students, including Sigmund Freud, MD.¹
MS is a disabling disease of the central nervous system (CNS), in which the immune system attacks the protective cover of the nerve fibers called myelin and causes miscommunication between the brain and the rest of the body. Eventually, the disease progresses to permanently damage and deteriorate most nerves. Sign and symptoms of the disease may include numbness or weakness in 1 or more limbs, which starts on 1 side of the body or leg and moves to the other. These patients complain of bladder and bowel function issues, double vision and vision changes, lack of coordination, slurred speech, tingling, tremors, and an unsteady gait. Most people with MS have a relapsing-remitting disease course with symptoms developing over days or weeks and then improving. At some point in the disease, the symptoms start to develop more steadily, turning the disease to secondary-progressive MS.²
More than 2.3 million people worldwide have been diagnosed with MS, and more than 1 million adults in the United States live with the disease. Most of these cases fall into 1 of 4 categories: clinically isolated syndrome; primary progressive; relapsing-remitting (the most common type); and secondary progressive.³
To diagnose MS, practitioners order blood tests to help rule out other disease conditions that may have similar symptoms. Tests also check for biomarkers associated with MS. A spinal tap or lumbar puncture, is another test to sample the cerebrospinal fluid, which will show abnormalities and antibodies that maybe associated with MS. A magnetic resonance imaging test is also a tool to find MS lesions on the brain and spinal cord. Finally, an evoked potential test is used to watch how quickly the information travels down the nerve pathways when stimulated.⁴ Throughout 1800s and 1900s, hundreds of MS therapies were tried, without success. These included arsenic, injection of malaria parasites, mercury, and use of nightshade, a plant with poisonous fruit. In 1951, cortisone, a steroid, was first used to treat MS relapses, also known as attacks or exacerbation. Cortisone was found to help with reducing the severity of the symptoms of the relapse and shorten their duration but showed no long-term benefit for prevention of MS.⁵
Depending on the type of MS, treatment options may differ. The sooner the disease is diagnosed, and an aggressive treatment started, the more successfully it can lower the relapse rate, potentially reduce the risk of brain atrophy, and slow the formation of new lesions. For primary-progressive MS, ocrelizumab (Ocrevus) is the only FDA-approved disease-modifying agent. Treatment options for relapsing-remitting MS include various injectables and oral medications. Injectables include interferon beta. Glatiramer acetate (Copaxone, Glatopa), approved in October 2017, is another injectable that can help block the immune system’s attack on myelin. Oral treatment options include fingolimod (Gilenya), approved in December 2019, which is a once-daily oral medication reducing the relapse rate.
Dimethyl fumarate (Tecfidera), approved in May 2020, is a twice-daily oral medication that can reduce relapses. Diroximel fumarate (Vumerity), approved in October 2019, is a twice-daily capsule for relapsing forms of MS. Teriflunomide (Aubagio) is a once-daily oral medication, reducing the relapse rate, approved by FDA in September 2012. Siponimod (Mayzent), is a recent addition to the treatment options for secondary-progressive MS, a once-daily option approved by the FDA in March 2019. Cladribine (Mavenclad), also approved in March 2019, is a second-line treatment for those with relapsing-remitting MS. Cladribine was approved for secondary-progressive MS.
When it comes to infusion treatment options, there are few choices that FDA has approved for the primary-progressive and relapse-remitting forms of MS. One is ocrelizumab (Ocrevus), approved in March 2017, given as intravenous infusion. Another option is Natalizumab (Tysarbi), approved since 2006, which is a first-line treatment for some patients with severe MS and is a second line for others. Alemtuzumab (Campath, Lemtrada), another infusion therapy available since 2014, helps reduce relapses of MS by targeting immune cells and depleting white blood cells.
These treatment options while effective, may have multiple adverse effects, including blood pressure and heart rate changes, blurred vision, diarrhea, flu-like symptoms, flushing, injection-site reactions, liver damage, nausea, and low white-blood-cell count. Other therapies may cause harmful effects to the fetuses of pregnant women, headaches, liver problems, progressive multifocal leukoencephalopathy, thyroid abnormalities, tumors, upper-respiratory infections, and viral and other infections.
Other treatment options include muscle relaxers, occupational and physical therapy, and medications to reduce fatigue, such as Amantadine, Modafanil, and Ritalin. Medications such as Dalfampridine (Ampyra) may also help slightly increase walking speed for patients with MS. Finally, other medications may be used to relief MS symptoms, such as bladder or bowel control, depression, insomnia, pain, and sexual dysfunction.4
There are many MS treatment options available, which offer a better prognosis for these patients. The key to better outcomes for patients with MS is to increase awareness about early diagnosis and treatment.
Saro Arakelians, PharmD, is the general manager and pharmacist in charge at BioScrip Infusion in Burbank, California.