Managing the disease course

RATE

Several medications called disease-modifying treatments (DMTs) or disease-modifying drugs (DMDs) have been shown to be effective in decreasing the frequency of relapses or exacerbations and decreasing the development of lesions or plaques in the brain or spinal cord. Although these medications are effective in the majority of cases of MS, they have not proven to be effective in cases of primary-progressive MS (PPMS), the disease course that is gradually progressive from the start and doesn’t involve relapses or exacerbations.

 

First-line disease-modifying treatments

Injectable disease-modifying therapies are considered by most doctors to be first-line options, in other words, the initial choice of drug therapy for treating patients who are diagnosed with MS. The majority of these are interferon beta drugs which include the injectable medications Betaseron (interferon beta-1b), Avonex (interferon beta-1a), Rebif (interferon beta-1a)Extavia (interferon beta-1b), and Plegridy (Peginterferon beta-1a). While the active ingredients in some of these products may be the same, different brands may be formulated slightly differently.

Injectable interferon beta drugs are FDA approved to treat all relapsing forms of MS, including relapsing-remitting MS (RRMS), secondary-progressive MS (SPMS), and progressive-relapsing MS (PRMS). Betaseron, Avonex, and Extavia are also approved for delaying a second exacerbation in people who have been diagnosed with clinically isolated syndrome (CIS).

Another injectable disease-modifying therapy, Copaxone (glatiramer acetate) is not an interferon beta drug, but a synthetic polypeptide. It is approved for RRMS, as well as CIS.

There are currently three oral disease-modifying therapies available for MS, Gilenya (fingolimod) and Aubagio® (teriflunomide) and Tecfidera (dimethyl fumarate) (formerly BG12), which are FDA approved for relapsing forms of MS. Gilenya is the first in a new class of oral MS medications called sphingosine-1-phosphate receptor modulators. Likewise, Aubagio is the first in a new class of oral MS medications called pyrimidine synthesis inhibitors. Tecfidera is a formulation of fumaric acid, which has been used to treat psoriasis for decades. These drugs are members of a group of drugs called immunomodulators. Like the injectable MS drugs, Gilenya, Aubagio and Tecfidera are approved as first-line agents and can be chosen as the initial treatment in patients newly diagnosed with relapsing forms of MS.

First-Line Disease Modifying Treatments for MS

Drug Manufacturer
Administration
Common side effects
Patient info/ Financial support
Avonex (interferon beta-1a)
Biogen Idec
Weekly by intramuscular injection
Most common: Flu-like symptoms following injection (lessen over time for many patients)
Less common: Depression, Mild anemia, Elevated liver enzymes, Liver toxicity
MS Active Source
1-800-456-2255
Avonex.com
Msactivesource.com
Betaseron (interferon beta-1b)
Bayer HealthCare Pharmaceuticals
Every other day by subcutaneous injection
Most common: Flu-like symptoms following injection (lessen over time for many people), Injection site reaction
Less common: Depression, Elevated liver enzymes, Low white blood counts
BETAPLUS
1-800-788-1467
Betaseron.com
Extavia (interferon beta-1b)
Novartis Pharmaceuticals
Every other day by subcutaneous injection
Most common: Flu-like symptoms following injection (lessen over time for many people), Injection site reaction
Less common: Depression, Elevated liver enzymes, Low white blood counts
Extavia Patient Support Program
1-866-925-2333
Rebif (interferon beta-1a)
EMD Serono, Immunex
Three times per week by subcutaneous injection
Most common: Flu-like symptoms following injection (lessen over time for many people), Injection site reaction
Less common: Elevated liver enzymes, Low white blood counts
MS Lifelines
1-877-44-REBIF
Rebif.com
Mslifelines.com
Copaxone (glatiramer acetate)
Teva Pharmaceuticals Industries
Daily or three times per week by subcutaneous injection
Most common: Injection site reactions
Less common: Reaction immediately after injection involving anxiety, chest tightening, shortness of breath, flushing (lasts 5-10 min, with no known long-term effects)
Shared Solutions
1-800-887-8100
Sharedsolutions.com
Gilenya (fingolimod)
Novartis Pharmaceuticals
Everyday by capsule orally
Most common: Headache, Diarrhea, Liver enzyme elevations, Flu, Back pain, Cough
Less common: Slowed heart rate after first dose, Swelling in eye, Infections
Patient Support Program
1-877-408-4974
Gilenya.com
Aubagio (teriflunomide)
Sanofi, Genzyme
Everyday by tablet orally
Most common: Diarrhea, Abnormal liver tests, Flu, Hair thinning, Nausea
Warnings: Liver damage, Fetal damage
Genzyme Medical Information Services
1-800-745-4447
Aubagio.com
Tecfidera (dimethyl fumarate)
Biogen Idec
Everyday by capsule (taken twice daily)
Most common: Flushing, Abdominal pain, Diarrhea, Nausea
Warnings: Lymphopenia, Flushing
MS ActiveSource
1-800-456-2255
Tecfidera.com
Plegridy (peg interferon beta-1a)
Biogen Idec
Every two weeks by subcutaneous injection
Most common: Injection site reaction, Flu-like symptoms, Headache
Less common: Liver damage, Depression and suicide, Seizure, Serious allergic reaction
MS ActiveSource
1-800-456-2255
Plegridy.com

Second-line disease-modifying treatments

There are two disease-modifying therapies that are given by IV infusion, Tysabri (natalizumab) and Novantrone (mitoxantrone). Both of these drugs are typically used as second-line drug treatment options in the US, which means that they are reserved for people who have not responded adequately to first-line drugs. Tysabri is a monoclonal antibody approved for relapsing forms of MS and Novantrone is an antineoplastic drug (anticancer drug) approved for SPMS, PRMS, and worsening RRMS.

 

First-Line Disease Modifying Treatments for MS

Drug/ Manufacturer
Administration
Common side effects
Patient info/Financial support
Tysabri (natalizumab)
Biogen Idec
IV infusion every 4 weeks in infusion center
More common: Headache, Fatigue, Urinary tract infections, Depression, Chest discomfort, Lower respiratory tract infections, Joint pain,
Less common: Allergic or hypersensitivity reactions within 2 hrs of infusion (dizziness, fever, rash, itching, nausea, flushing, low blood pressure, difficulty breathing, chest pain)
MS Active Source
1-800-456-2255
Tysabri.com
Novantrone (mitoxantrone)
Serono, Immunex
4 times yearly by IV infusion in medical facility
Lifetime cumulative dose limit approx 8-12 doses over 2-3 yrs
Most common: Blue-green urine 24 hrs after administration, Infections, Bone marrow suppression (fatigue, bruising, low blood counts), Patient must be monitored for serious liver and heart damage, Nausea, Hair thinning, Bladder infections, Mouth sores
1-877-447-3243
Novatrone.com

 

How do you choose between different disease-modifying therapies?

With so many disease-modifying-therapies available, it is important to know the differences between these drugs so that you and your doctor might select one over another for your treatment. Some of the drugs described above are indicated (approved for a specific use) as the initial or first-line treatment for persons with MS and/or CIS. Others (Tysabri and Novantrone) are second-line treatment option for persons have not responded adequately to a first-line drug. In some cases, the choice among drugs is made according to the following considerations:

  • Side effects associated with each
  • MS disease course, as some drugs may be more effective than others in one disease course versus another
  • Lifestyle considerations, such as whether a person is able to give him or herself an injection
  • Desire to become pregnant, as some drugs are not recommended during pregnancy
  • Insurance coverage