How to Choose an MS Medication in 3 Not-So-Easy Steps

So, you’ve decided to take a disease-modifying therapy (DMT) to try to keep your MS at bay. As a caregiver, I have been actively involved in researching and discussing therapeutic options for years. With 23 FDA-approved medications, it is not a simple choice.

Those who were diagnosed in the 1990s had a choice of only three FDA-approved medications (Betaseron, Avonex, and Copaxone). By 2010, there were seven approved DMTs. With a staggering array of choices in 2021, patients need to discuss the decision with their neurologist and do some independent research with the help of their support partners.

Which DMT should I choose for my MS treatment?

Experts say that choosing a treatment often comes down to three factors.

#1: How effective is the DMT?

It is difficult to comparison shop the available DMTs because they are compared to different medications in clinical trials. In other words, there is no standard used to compare. If Drug A is “30% more effective than (older) Drug X” and Drug B is “35% more effective than (older) Drug Y,” then how can one decide between Drug A and Drug B?

A 2015 study by the independent Cochrane Group provides some guidance, but it did not cover the medications that have been approved over the past several years.¹ Also, you are dealing with statistical probabilities and not a patient’s individual case.

#2: How safe is the DMT?

The U.S. Food and Drug Administration (FDA) and the European Commission test and regulate medications. The difference between the two has been described as: “The FDA is sometimes seen as overplaying safety concerns at the cost of commercial enterprise, whereas the European systems are sometimes characterized as being primarily concerned with preserving commercial interests to the detriment of patient safety.”²

In either case, the agencies are approving DMTs that have been proven safe over a relatively short time. Some patients are willing to rely on clinical trials and subsequent government approval, while others prefer to choose a DMT that has a longer safety record.

David Jones, M.D., a neurologist with the Miller Multiple Sclerosis Clinic at the University of Virginia, summed up the issue as follows: "Many older agents are seemingly less effective, but have a well-defined safety profile. Many newer agents appear more effective but come with more safety issues. This puts individuals with MS in a bit of a quandary. Do you want more safety or more efficacy?"³

#3: How is the DMT taken?

There are three ways to administer MS medications: pill, injection, or infusion. This is a highly personal choice. Patients should favor the option that they are most likely to adhere to over the long haul.

Other considerations or tiebreakers

Once a patient has narrowed the choice to two or three medications, it becomes difficult to decide. One obvious consideration is potential side effects. They can range from headaches and nausea to more serious concerns.

Another, less discussed, consideration is how the DMT is made. Most drugs are “small molecule” meaning they are produced using chemicals. These drugs, such as aspirin, can enter cells easily because they have a low molecule weight. A smaller but increasing number of drugs are “large molecule.” They are known as “biologics” and are taken from living organisms, so they are naturally derived.

There is a trend towards biologics because they are better-targeted and tend to cause fewer side effects.⁴ However, small molecule DMTs are more economical and more accessible to patients.⁵

The bottom line

Choosing an MS drug normally involves a long-term commitment. You need time to see if the DMT works for you. You might want to use a process of elimination. If you hate needles, you can eliminate injectables; if you hate swallowing pills, you can eliminate oral DMTs. If you want the most powerful drug available, then you can eliminate older medications.

Finally, make the decision yourself, but only after doing some basic research and consulting with your physician and your support team. You’re not in this alone!