Multiple Sclerosis
From TOP to BOTTOM
Getting the Complete Picture
Multiple Sclerosis is a neurodegenerative and inflammatory immune condition that causes problems throughout the body. Pinpoint
the disease’s effects from head to toe.
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The Effects of MS on the Body Systems
Multiple sclerosis (MS) is thought to be an autoimmune disease and progressive neurodegenerative condition. It affects the
nervous system, which gradually impacts the whole body. The Multiple Sclerosis Foundation (MSF) reports that as many as half a
million people in the United States have been diagnosed with MS, and hundreds more diagnoses are made every week (MSF,
2009). Women are diagnosed with MS at least twice as often as men—usually between the ages of 20 and 50—according to the
National MS Society (NMSS).
The exact cause of MS is unknown, and there is currently no cure. However, there are many treatments available that can slow the
disease’s progression or ease its symptoms. Although everyone’s experience with MS is different, there are
common symptoms that occur throughout the body for many individuals.
Learn four possible causes of multiple sclerosis »
The Nervous System
When someone has MS, their body’s immune system slowly attacks its own myelin sheath, which is composed of
the cells that surround and protect the nervous system including the spinal cord and brain. When these cells are damaged, the
nerves are exposed, and the brain has difficulty sending signals to the rest of the body.
The disconnection between the brain and the organs, muscles, tissues, and cells served by the damaged nerves causes many of the
classic MS symptoms, such as dizziness, vertigo, confusion, memory problems, and emotional or personality changes. Depression
and other changes in the brain can be a direct result of MS or an indirect result from the difficulty of coping with the condition.
In rare or advanced cases, nerve damage can cause tremors, seizures, and cognitive problems that closely resemble other
neurodegenerative conditions such as dementia.
Vision and Hearing
Vision problems are often the first sign that something is wrong for many people with MS. Double vision,
blurriness, pain, and problems seeing contrast can begin suddenly and affect one or both eyes. In many cases, vision problems are
temporary or self-limiting, and likely result from nerve inflammation or fatigue of the eye muscles.
Although some people with MS experience permanent vision problems, most cases are mild and can be effectively treated with
steroids and other short-term treatments.
Although it’s rare, people with MS may experience hearing loss or deafness. These types of hearing problems usually resolve on
their own, but can be permanent in some cases. Most hearing problems are due to damage to the brainstem. These conditions are
so rarely caused by MS that patients should be evaluated for potential unrelatedcauses.
Speaking, Swallowing, and Breathing
According to NMSS, speech problems such as slurring, poor articulation, and volume control issues occur in up
to 4 out of 10 individuals with MS (NMSS). They often occur during relapses or times of fatigue. Other speech problems can
include changes in voice pitch or quality, nasality, and hoarseness or breathiness.
Speech problems can be caused by breathing difficulties that are brought on by weak or damaged nerves that control muscles in
the chest. Difficulty controlling the muscles involved in breathing can begin early in the disease and worsen as MS progresses.
This is a dangerous yet rare complication of MS that often can be improved through work with a respiratory therapist.
Swallowing problems are less common than speech difficulties, but can be far more serious. They may occur when nerve damage
weakens muscles and hinders the body’s ability to control the muscles involved in swallowing. When proper swallowing is
disrupted, food or drink can be inhaled into the lungs and may result in infections like aspiration pneumonia. Coughing and
choking when eating and drinking can be signs of swallowing problems and should be evaluated immediately. Speech or
language therapists can often help with trouble speaking and swallowing.
Arms and Legs
Many people with MS experience a wide variety of symptoms that affect their limbs. Damage to the myelin
sheath often results in pain, tingling, and numbness of the arms and legs. Problems with hand-eye coordination, muscle weakness,
balance, and gait may occur when the brain has trouble sending signals to the nerves and muscles.
These problems may start slowly and worsen as nerve damage progresses. Many people with MS first feel “pins and needles” and
have difficulty with coordination or fine motor skills. As the condition worsens, limb control and ease of walking
may become disrupted. In these cases, canes, wheelchairs, and other assistive technologies can aid in muscle control and strength.
The Skeletal Structure
People with MS are at higher risk of developing osteoporosis due to common MS treatments (steroids) and
inactivity, according to NMSS (NMSS). Weakened bones can make individuals with MS susceptible to fractures and breaks.
Although conditions like osteoporosis can be prevented or slowed through physical activity, diet, or supplementation, weak bones
can make MS balance and coordination problems even riskier.
A growing body of evidence suggests that vitamin D deficiencies may play an important role in the development of MS. Although
its exact impact on individuals with MS is not yet well understood, vitamin D is vital to skeletal health and immune system health
(Zabad, 2010).
The Immune System
Most researchers and medical professionals believe that MS is an immune-mediated disease. This means that the
body’s immune system attacks healthy nerve tissue, which results in nerve damage that affects the whole body. Immune system
activity seems to result in the inflammation responsible for many MS symptoms. Some symptoms may flare up during an episode
of immune system activity and resolve when the episode ends.
Some research is investigating whether suppressing the immune system with medication will slow the progress of MS. Other
therapies try to target particular immune cells to prevent them from attacking the nerves. However, drugs that suppress the
immune system may make patients more vulnerable to infection.
Some nutrient deficiencies may affect immune health and worsen MS symptoms. However, most MS physicians only recommend
special diets when a specific nutrient deficiency is present.
Bladder and Bowel Function
Problems with bladder and bowel function commonly occur in MS. NMSS reports that at least 8 in 10 people with MS experience
bladder dysfunction (NMSS). Bowel problems can include constipation, diarrhea, or loss of bowel control. In some cases, diet and
physical therapy or self-care strategies can reduce the impact of these problems on daily life. Other times, medications or more
intense intervention may be necessary.
The use of a catheter may occasionally be necessary. This is because nerve damage affects how much urine those with MS can
comfortably hold in the bladder. This can result in a spastic bladder or urinary tract (UTIs), bladder, or kidney infections. These
problems can make urination painful and very frequent, even overnight or when there is little urine in the bladder.
Most people can effectively manage bladder and bowel problems and avoid complications. However, serious infections or hygiene
problems may arise if these problems are left untreated or unmanaged. Discuss any bladder or bowel issues and their treatment
options with your doctor.
The Reproductive System
MS does not directly impact the reproductive system or fertility. In fact, many women find that pregnancy offers
a nice reprieve from MS symptoms. However, NMSS reports that two to 4 in 10 women will experience a relapse during the
postpartum period (NMSS).
Sexual dysfunction, such as difficulty experiencing arousal or orgasm, is common in people with MS. This can be caused by nerve
damage or by MS-related emotional problems such as depression or low self-esteem. Fatigue, pain, and other MS symptoms can
make sexual intimacy awkward or unappealing. However, in many cases, sexual problems can be addressed successfully through
medication, over-the-counter aids (such as lubricant), or a bit of advanced planning.
The Circulatory System
Circulatory system problems are rarely caused by MS, although weak chest muscles can lead to shallow breathing
and low oxygen supply. However, lack of activity due to depression, difficulty using muscles, and a preoccupation with treating
other problems may prevent people with MS from focusing on the risk of cardiovascular disease.
A recent study found that women with MS have a significantly increased risk of cardiovascular problems such as heart attack,
stroke, and heart failure (Jadidi et al., 2013). However, physical therapy and regular physical activity may help alleviate MS
symptoms and reduce cardiovascular risk.
Primary Versus Secondary MS Symptoms
Most of the problems described above are primary symptoms associated with MS. This means that they’re directly caused by the
nerve damage resulting from attacks to the myelin sheath. Some primary symptoms can be treated directly by trying to slow the
nerve damage and prevent MS attacks.
However, once nerve damage exists, secondary symptoms can arise. Secondary MS symptoms are common complications of
primary MS symptoms. Examples include UTIs that result from weak bladder muscles, or a loss of muscle tone that results from
an inability to walk.
Secondary symptoms can often be treated effectively, but treating the source of the problem can prevent them altogether. As the
disease progresses, MS will inevitably cause some secondary symptoms. Secondary symptoms can often be well-managed with
medication, physical adaptation, therapy, and creativity. Depression, job loss, isolation, and relationship problems are often
described as tertiary symptoms because they’re further removed from the actual course of the disease.
Treating MS from Head to Toe
While there’s no cure for multiple sclerosis, a wide variety of pharmaceutical treatments, herbal remedies, and dietary
supplements help alleviate symptoms and modify the disease.
Disease-Modifying MS Treatments
Disease-modifying medications include:

teriflunomide (Aubagio)

interferon beta 1a (Avonex, Rebif)

interferon beta 1b (Betaseron, Extavia)

glatiramer acetate (Copaxone)

fingolimod (Gilenya)

mitoxantrone (Novantrone)

dimethyl fumerate (Tecfidera)

natalizumab (Tysabri)
Disease-modifying medications for MS often aim to prevent or reduce the severity of MS attacks, slow or prevent further nerve
damage, and prevent further disability.
Physical and Alternative MS Treatments
No matter the stage of the disease, physical and non-medication therapies for MS can be very useful to treat symptoms. Popular
therapies include:

physical therapy

occupational therapy

speech therapy

vocational rehabilitation

cognitive rehabilitation
In addition, many people with MS use alternative treatments in place of or in addition to pharmaceuticals and the therapies listed
above. Alternative or complementary treatments could include herbal remedies, dietary supplements, and physical interventions.
Popular alternative MS treatments include:

bilberry leaf

ginger

vitamin D supplements

coenzyme Q10 supplements

massage

biofeedback
Although many alternative treatments for MS aren’t well researched, many people experience some relief with certain therapies.
Always discuss with your doctor before using them to avoid medication interactions or complications with existing health
problems.
Multiple sclerosis affects everyone differently: that is, you’ll experience a unique set of symptoms and respond to treatments
individually. Therefore, you and your doctors should customize your treatment regimen to address your MS symptoms
specifically and alter it as the disease progresses or relapses. A carefully designed treatment plan can help make MS a manageable
condition.
Multiple sclerosis (MS) is a progressive autoimmune disease. Autoimmune diseases mistake normal, healthy parts of the body as
foreign and attack them. In the case of MS, the body attacks and destroys the protective sheath that surrounds your nerves. This
sheath is called myelin. The damage to and destruction of the myelin eventually affects the nerves. Nerve damage delays and
disrupts communication between your brain and parts of the body.
MS is unpredictable. It fluctuates and changes from month to month and person to person. For some people, MS is only mildly
intrusive. The symptoms and signs of the disease are minuscule compared to more invasive conditions, such as a spinal cord
injury or stroke.
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However, that’s not the case for everyone. MS can also progress quickly. Flares can be very difficult, and recovery might not be
possible. Over time, MS destroys the myelin around your nerves. This damage cannot be repaired.
How Physical Therapy Helps People with Multiple Sclerosis
Each person’s MS progression is different. MS can be aggressive and become advanced quickly. In other cases, MS can be mild
and progress at a much slower pace, with long periods of inactivity.
In any case, physical therapy (PT) can be an important treatment option for people with MS. PT can help patients learn to cope
with their changing bodies, develop strength and stamina, and regain abilities after a disease flare.
Physical Therapy at Different MS Stages
At Diagnosis
By the time a diagnosis is made, you may already be experiencing symptoms of the disease. Still, it’s important you meet with a
physical therapist for a baseline evaluation. This exam allows the therapist to see what you are capable of now and compare that to
your future abilities. You can also discuss your physical limitations and understand what appropriate levels of exercise and
physical activity are. After a diagnosis, you may not need to continue seeing a physical therapist unless you wish to or if you have
an aggressive, rapidly progressing case of MS.
During a Relapse
A relapse, or flare, is a period of time when the signs and symptoms of MS are more prevalent. During this period, you may
experience greater difficulty with everyday tasks, including working, cooking, walking, and showering. Your physical therapist
will be able to understand how the flare is affecting you by conducting an exam and comparing it to your baseline evaluation.
Once the flare has ended, meet with your physical therapist again to resume PT. Therapy after a flare may help you regain some of
the strength you lost during the flare.
Progressive Multiple Sclerosis
If you have primary-progressive MS, you do not experience flares and remissions. Instead, your disease is on a gradual but
constant decline. If you are diagnosed with this type of MS, ask your doctor to refer you to a physical therapist right away. It’s
crucial to your health and well being that you start PT as soon as you can. PT can teach you how to compensate for the changes
you will experience. You may also need to learn how to use a mobility aid, such as a standing device or wheelchair.
Advanced Multiple Sclerosis
Patients with advanced MS experience significant disease burden. In most cases, people with advanced MS are non-ambulatory—
they cannot get around without aid from another person or a motorized device. Also, people at this stage have an increased risk of
developing secondary health conditions, such as osteoporosis and epilepsy.
Patients with advanced MS can still benefit from physical therapy. Namely, PT can help patients learn to sit properly, develop
upper body strength, and maintain the ability to use mobility aids.
Venues for Physical Therapy
Physical therapy can be conducted in several venues, including the home, an outpatient facility, a gym, or even MS treatment
centers. PT for MS may be different based on the venue you use. In some cases, the stage of the disease determines what type of
venue you require. In other cases, you may be able to select the option that works best for you and your lifestyle.
Inpatient (acute, transitional, rehabilitation, or long-term care)
PT conducted in an inpatient facility is often done in a hospital, MS treatment center, or long-term care facility. Most people who
require inpatient PT have experienced a fall or some type of injury because of their MS. People with advanced-stage MS may also
be living in an assisted-living center, and PT may be required as part of treatment.
Outpatient
PT that takes place in a doctor’s office, physical therapy office, or therapy center is considered outpatient. People who undergo
outpatient PT come to the venue for therapy and leave afterward. These venues are good for people who are recovering from a
relapse or learning to handle physical changes caused by MS.
Home care
People in all stages of MS can use home care. This type of therapy may be useful for people who have recently been diagnosed
with MS and are learning to deal with slight changes in their physical abilities. Home care can also be used for patients who are
experiencing late-stage MS and are non-ambulatory. Instead of going to an outpatient facility, a physical therapist may visit a
patient and conduct PT in the home if their MS is advanced.
Making Treatment Plans
If you have been diagnosed with MS, talk with your doctor about your course of treatment. If you would like to begin working
with a physical therapist, ask your doctor for a referral. Even in the earliest stages of the disease, people with MS need to learn
how to support their bodies, avoid exacerbating symptoms, and use mobility aids as necessary. A discussion with a physical
therapist can also help you understand how your body will change as the disease progresses and how you can prepare for these
changes by building strength, maintaining or improving your healthy lifestyle, and incorporating therapeutic activities.
Therapy Options
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Maintaining a Healthy Mind
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The battle against multiple sclerosis (MS) has advanced considerably in recent years. A number of drugs are effective in
alleviating symptoms and helping combat relapses. However, as with any disease, it’s crucial to first understand the benefits and
risks of specific treatment options, and then work with your doctor to choose the therapy that’s best for you.
Take the MS Assessment now and discuss your results and treatment options with a neurologist »
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There are several main groups of drugs used to treat MS. The groups are:

interferons, including interferon beta-1a and interferon beta-2a

biological drugs

monoclonal antibodies

pyrimidine synthesis inhibitor

sphingosine 1-phosphate receptor modulator

immunomodulator

antineoplastic drugs (also used to treat cancer)
Interferons
Avonex (interferon beta-1a)
Company: Biogen
Description: Avonex treats relapsing-remitting MS (RRMS) and was approved for use in the United States in 1996. Avonex is
an interferon. Interferons are messenger proteins produced by the body to regulate the immune response. Avonex works to prevent
the immune system from attacking the central nervous system. This reduces the number and severity of flare-ups. It has proven to
be relatively safe and effective in reducing the progression of physical disability due to MS. It reduces the occurrence of relapses
and reduces the number of lesions appearing on follow-up MRI. There is no generic version available.
Treatment: Intramuscular injection (into the muscle) once a week.
Side effects: Flu-like symptoms that typically lesson over time, including:

headache

fatigue

nausea or stomach pain

fever

body or muscle aches

chills

dizziness
Your doctor may recommend that you take an over-the-counter nonsteroidal anti-inflammatory drug (NSAID) to help reduce the
discomfort from these side effects.
Less common side effects include:

depression

mild anemia

irritation or rash at the injection site

liver abnormalities

allergic reactions

heart problems (rapid or slow heart rates, or chest pain)

thyroid problems

bone marrow suppression (lower counts of cells in the blood)
Results: Studies investigating the treatment of RRMS with Avonex have shown a significant reduction in the number of people
who have progressed to a disability score above 6.0 on the Kurtzke Expanded Disability Status Scale (EDSS).
Rebif (interferon beta-1a)
Companies: EMD Serono Inc. and Pfizer
Description: Rebif is approved for treatment of RRMS. Rebif is a type of interferon. Rebif is similar to Avonex, but it’s made by
a different manufacturer and is dosed differently. Interferons are messenger proteins produced by the body to regulate the immune
response. Rebif works to prevent the immune system from attacking the central nervous system. This reduces the number and
severity of flare-ups. It has proven to be relatively safe and effective in reducing the progression of physical disability due to MS.
It reduces the occurrence of relapses and reduces the number of lesions appearing on follow-up MRI. There is no generic version
available.
Treatment: Subcutaneous injection (beneath the fat layer under the skin) three times per week.
Side effects: Flu-like symptoms that usually lessen over time, which can include:

headache

fatigue

nausea or stomach pain

fever

body or muscle aches

chills

dizziness
Your doctor may recommend that you take an over-the-counter NSAID to help reduce the discomfort from these side effects.
Less common side effects include:

depression

mild anemia

irritation or rash at the injection site

liver abnormalities

allergic reactions

heart problems (rapid or slow heart rates, or chest pain)

thyroid problems

bone marrow suppression (lower counts of cells in the blood)
Results: The drug, which has more than 17 years of clinical trial and patient use, is designed for those with RRMS. People who
took the drug for two years showed a 78 percent reduction in lesions, a reduced need for steroid treatments, and fewer
exacerbations. The Food and Drug Administration (FDA) approved Rebif Rebidose in early 2013. It consists of a color-coded
auto-injector for convenience.
Plegridy (peginterferon beta-1a)
Company: Biogen
Description: Plegridy is approved for RRMS. It’s a “pegylated” form of interferon, in which a chemical called polyethylene
glycol is attached to the drug molecules. This helps the drug maintain its effects in the body for a longer amount of time. Its action
is similar to other beta-1a interferons, but it stays active in the body much longer. There is no generic version available.
Treatment: Subcutaneous injection (beneath the fat layer under the skin) in your stomach (abdomen), back of upper arm, or thigh
every two weeks using the Plegridy Pen auto-injector or a prefilled syringe.
Side effects: Common side effects include flu-like symptoms, including:

headache

chills

muscle aches

weakness

fever

injection site itching, swelling or pain (Use a different place for the injection each time to reduce this effect.)

nausea or vomiting
More serious side effects can include:

liver problems

worsening of liver problems that should be monitored by a doctor

suicidal thoughts and depression

seizures

congestive heart failure in patients with pre-existing cardiac disease

bone marrow suppression (lower counts of cells in the blood)
Results: The FDA approved Plegridy for use as a disease-modifying therapy in August 2014. It’s designed to maintain the effects
of interferon in the body for a longer period of time than previously available versions of interferon. People in the study showed a
67 percent reduction in new or newly enlarging lesions in a clinical trial. They also showed a 36 percent reduction in relapse rate
compared to placebo at 48 weeks, according to theprescribing information.
Interferon beta-1b
Betaseron (interferon beta-1b)
Company: Bayer HealthCare Pharmaceuticals
Description: Betaseron is an interferon and was approved for use by the FDA in 1993 to treat RRMS. It has been shown to be
effective in people who had their first clinical episode or who have features of MS confirmed by MRI. Interferon beta is a protein
that’s normally manufactured by the body. The drug is made from human blood plasma. It works by reducing the body’s immune
response that attacks nerve cells. It reduces inflammation by reducing the immune response in the central nervous system. It also
reduces the number and severity of flare-ups and stabilizes the lesions (or nerve damage) as well. There is no generic form
available.
Treatment: Subcutaneous injection (under the skin), every other day. The outer surfaces of the arms, abdomen, hips, and thighs
may be used, rotating sites each time.
Side effects: Flu-like symptoms that typically lessen over time. These can include:

headache

fatigue

nausea or stomach pain

fever

body or muscle aches

chills

dizziness
Your doctor may recommend that you take an over-the-counter NSAID to help reduce the discomfort from these side effects. It’s
also common to have injection site reactions, such as itching, redness, or pain.
Less common side effects can include:

more severe injection site reactions, such as hives

depression

liver abnormalities

allergic reactions

low white blood cell count

seizures

thyroid problems
Results: One clinical trial found that the drug reduces onset of MS by 50 percent in the first two years among people with MS
who display clinically isolated syndrome (CIS).
Extavia (interferon beta-1b)
Company: Novartis Pharmaceutical
Description: Extavia is very similar to Betaseron. It reduces inflammation and the frequency and severity of attacks. It was
approved for use in 2009 to treat RRMS. It has been shown to be effective in patients who had their first clinical episode or who
have features of MS confirmed by MRI. There is no generic version available.
Treatment: Subcutaneous injection (under the skin), every other day. The outer surfaces of the arms, abdomen, hips, and thighs
may be used, rotating sites each time.
Side effects: You may have flu-like symptoms that typically lessen over time. These can include:

headache

fatigue

nausea or stomach pain

fever

body or muscle aches

chills

dizziness
Your doctor may recommend that you take an over-the-counter NSAID to help reduce the discomfort from these side effects. It’s
also common to have injection site reactions, such as itching, redness, or pain.
Less common side effects can include:

more severe injection site reactions, such as hives

depression

liver abnormalities

allergic reactions

low white blood cell count

seizures

thyroid problems
Results: In a clinical study, the percent of MRIs showing new or expanding lesions was 29 percent in the placebo group and 6
percent in the group receiving treatment.
Biological Drugs
Copaxone (glatiramer acetate)
Company: Teva
Description: Copaxone is a biological drug, approved for use in 1996 to treat RRMS. It’s made of manufactured proteins that are
similar to myelin, the natural protein that wraps nerve cells. It blocks the activity of T cells, which are white blood cells. T cells
play a role in damaging the myelin wrapper around nerves. Although the way it works isn’t entirely clear, it’s believed to act as a
sort of decoy for the attention of inflammatory cells. Copaxone may also stimulate cellular activity that prevents damage to nerve
fibers.
Generic version available: Glatopa, glatiramer acetate 20 mg/mL injection made by Sandoz, was approved on April 16, 2015.
Treatment: Subcutaneous injection (just beneath the fat layer of the skin), once per day. Copaxone is available in two strengths
(20 mg/mL and 40 mg/mL) and is dosed either once a day or three times a week, as determined by your doctor.
Side effects:

injection site reactions

dilation of blood vessels

chest pain

tremor (involuntary shaking)

weakness

nausea or vomiting

back pain

runny nose or cough

headache

skin rash
Some people experience chest pain as long as a month after starting the drug. Call your doctor if you experience this.
A post-injection reaction may occur in a small minority of patients. It can last about 15 minutes and may consist of:

anxiety

chest pain

heart palpitations

flushing

shortness of breath
Call your doctor right away if you have this reaction. This reaction usually happens just once and will disappear on its own, but
you must talk to your doctor about whether you should continue the drug if you have this reaction.
Results: The synthetic polypeptide has a consistent track record of improving immune system function and reducing
exacerbations. Long-term drug study results show that Glatiramer cut the relapse rate in half during the first year of treatment, and
for two thirds of patients, the EDSS scores remained stable or improved over the entire 10 year follow-up period. Copaxone also
requires fewer lab tests for safety monitoring than other treatments for RRMS.
Pyrimidine Synthesis Inhibitor
Aubagio (teriflunomide)
Company: Sanofi/Genzyme
Description: Aubagio is a disease-modifying therapy. The FDA approved it in September 2012 for the treatment of RRMS. It’s a
pyrimidine synthesis inhibitor. This reduces the number of white blood cells and also reduces inflammation. It may reduce the
number of active white blood cells in the central nervous system and prevent damage to nerve cells in MS. The exact method of
action is unknown.
Treatment: Oral tablet taken once daily.
Side effects:

headache

changes in liver function test results

diarrhea

thinning hair

nausea

pain

tingling sensation in fingers or toes (peripheral neuropathy)

increased blood pressure
Serious side effects may include:

liver toxicity

bone marrow suppression (reduced number of white or red blood cells)

increased risk of infections, such as tuberculosis

respiratory effects, including infections or bronchitis
Aubagio should not be taken by women who are pregnant or who might soon become pregnant. Like other potent diseasemodifying agents, this drug can increase the risk of certain infections. You should be tested for tuberculosis before starting
therapy. Regular monitoring of liver function and blood pressure should also be done.
Results: Trials show that Aubagio can significantly reduce the rate of relapses. The higher dose of the drug has also been shown
to reduce disability progression, compared to placebo. Aubagio is related to a similar drug used to treat the autoimmune disease,
rheumatoid arthritis.
Sphingosine 1-Phosphate Receptor Modulators
Gilenya (fingolimod)
Company: Novartis Pharmaceutical
Description: Gilenya is a sphingosine 1-phosphate receptor modulator (S1P-receptor modulator). It’s similar in structure to
naturally occurring cell surface receptors. This means it keeps destructive T cells from leaving the lymph nodes and crossing the
blood-brain barrier, where they can attack nerves in the central nervous system.
The FDA approved Gilenya in November 2010 to treat adults with RRMS to reduce the frequency of relapse and delay physical
disability. There is no generic version.
Treatment: Capsule taken orally every day.
Side effects:

headache

flu-like symptoms

diarrhea

back pain

liver enzyme elevations

cough
Serious side effects can include:

slowed heart rate following the first dose

increased risk of infections, including influenza, herpes, and bronchitis

swelling within the eye that could affect vision
You must undergo heart function monitoring for at least six hours when you first start the drug. This is because of the possibility
of a dangerously slow heartbeat. People with pre-existing heart disease shouldn’t take the medication. Some other prescription
drugs can increase this effect. Tell your doctor about all the drugs you’re taking before taking fingolimod.
Results: The drug is the first in a new class of immune modulating (regulating) drugs, which reduce damage to the central
nervous system and increase the repair of damaged neurons. Gilenya has shown the ability to reduce relapse rates by 60 percent
and reduce the progression of MS by up to 82 percent when measured with an MRI.
Monoclonal antibody
Lemtrada, Campath (alemtuzumab)
Company: Sanofi/Genzyme
Description: Lemtrada (another brand is Campath-1H) is a humanized monoclonal antibody that attacks CD52, which is a protein
found on the surface of dangerous white blood cells. Lemtrada is used to treat adults with RRMS. It was originally approved to
treat a type of leukemia at a much higher dosage. When used to treat leukemia, the drug would help destroy cancer-causing cells.
Though the mechanism of this drug’s effect on MS is not known, scientists believe it binds to CD52 sites on white blood cells,
which makes those and other white blood cells break down. This could help prevent those cells from damaging nerves.
Because it can cause several serious side effects, the FDA recommends that alemtuzumab only be prescribed to people who have
had a poor response to at least two other MS drugs first. There is no generic version.
Treatment: The recommended dosage of Lemtrada is 12mg each day, given intravenously (IV). The first treatment is 12mg each
day for five days in a row, for a total of 60mg. 12 months later, a second treatment is given, which is also 12 mg per day, for three
days in a row.
Side effects:

rash

headache

fever

nausea and/or vomiting

fatigue

nasal congestion

insomnia
Serious side effects from taking this drug have occurred and some patients have died. This medication has a boxed warning, which
is the most serious drug warning the FDA provides. These side effects include:

Serious autoimmune conditions have happened to people treated with this drug. These include immune thrombocytopenia
(severely reduced numbers of platelets, which help blood clot) and anti-glomerular basement membrane disease, which
causes damage to the kidneys.

Bone marrow suppression, which means the body can’t make enough white or red blood cells.

Serious or fatal infections can occur, caused by bacteria, viruses, fungi, or protozoa (single-celled organisms). You may
be given preventative treatment for some infections, if you are given this drug for MS.

Infusion reactions can occur. These are reactions to the intravenous treatment itself and can happen during treatment and
for up to 24 hours afterward.

Higher risk of cancer, including thyroid cancer, melanoma, and other cancers.

A number of people have developed autoimmune thyroid disease after taking this drug. Your doctor should monitor your
thyroid function carefully if you are given this drug.
More detail about side effects is included in the product’s prescribing information.
Due to these warnings, alemtuzumab is only available through a risk evaluation and mitigation strategy (REMS) program. The
REMS program ensures that patients are well educated about monitoring their health while being treated with this drug. If you
take this drug, you’ll need monthly blood tests for at least four years after you receive your last dose.
Results: Lemtrada required extra clinical trials before it was approved by the FDA in November 2014. It was compared to EMD
Serono’s MS drug, Rebif, in two phase 3 trials. It showed a superior effect at preventing MS relapses and also did a better job of
preventing disability over a two-year period. People taking Lemtrada were roughly 55 percent less likely to relapse over a twoyear period compared to patients taking Rebif in one clinical trial, according the product’s prescribing information. It hasn’t been
compared directly to other disease-modifying treatments.
Tysabri (natalizumab)
Companies: Biogen and Perrigo (formerly Elan Pharmaceuticals)
Description: Tysabri is approved for the treatment of RRMS. It’s generally used for people who have seen no improvement with
other MS treatments. Tysabri is a laboratory-produced monoclonal antibody that prevents certain while blood cells from attaching
and moving from the blood into the central nervous system. There is no generic version of this drug available.
Treatment: Given as an intravenous infusion in a medical facility every four weeks.
Side effects:

headache

fatigue

depression

urinary tract infections

vaginal infections

lower respiratory tract infections (pneumonias)

joint pain

chest discomfort
Serious side effects include allergic or hypersensitivity reactions after intravenous infusion. Symptoms can include:

fever

rash

dizziness

nausea

flushing

low blood pressure

breathing difficulties

chest pains
It’s also important to test for progressive multifocal leukoencephalopathy (PML). PML is a rare but often fatal brain infection,
which is caused by the John Cunningham virus (JCV). Due to these warnings, natalizumab is only available through a REMS
program. The REMS program ensures that patients are well educated about monitoring their health while treated with this drug.
Results: The FDA approved Tysabri in 2005. Studies show that the drug can slow progression of disability and help reduce
relapses. It may also help reduce fatigue and improve cognitive functioning related to MS. Tysabri reduced the rate of clinical
relapse at one year by 68 percent in one study. The drug also resulted in 92 percent fewer lesions compared to placebo at both one
and two years as measured by MRI.
Antineoplastic Drug
Mitoxantrone
Companies: Fresenius Kabi, Hospira, Pfizer, and Teva
Description: Mitoxantrone is an immunosuppressant drug originally used to treat certain types of cancer. It’s also approved for
use in people withprogressive-relapsing MS (PRMS), secondary-progressive MS (SPMS), and worsening RRMS. It hasn’t
been approved for the treatment of primary-progressive MS (PPMS). The drug decreases lesions and stabilizes MS in some
people. This drug is available only in generic form.
Treatment: Intravenous infusion in a medical facility four times a year. For safety reasons, the use of this drug is limited. The
lifetime dosage limit is typically between eight to 12 doses over two to three years.
Side effects:

changes in heart rhythm and function

water retention (bloating)

discolored urine following administration

infections

bone marrow suppression

nausea and/or vomiting

hair thinning

bladder infections

mouth sores
It’s also necessary to monitor for signs of serious liver and heart damage, changes in kidney function, cardiac disease, and
leukemia. Also, the medication may cause possible transient (blue) discoloration of the whites of the eyes and the urine. There is a
lifetime limit on how much of the drug a patient may receive because of the risk of cumulative damage to heart muscle. Due to
serious side effects, this drug is reserved for patients with rapidly progressing MS who have not had good results with at least two
other treatments, according to The American Academy of Neurology.
Results: The drug works by suppressing the immune system. This decreases inflammatory damage to the myelin that surrounds
nerves. It’s used for relapsing-remitting, progressive-relapsing, and secondary-progressive forms of MS. The drug was approved
in 2000. It has a track record of improving EDSS scores and reducing relapses. In a clinical trial, 90 percent of patients taking the
drug in combination with methylprednisolone showed no sign of lesions after six months.
Immunomodulators
Tecfidera (dimethyl fumarate)
Company: Biogen
Description: Tecfidera is the third approved oral disease-modifying drug for MS, according to the National MS Society. It was
approved in March 2013 for people with RRMS. It was formerly known as BG-12. The action of dimethyl fumarate in MS is not
certain, but it may prevent oxidative stress. Also, it may prevent inflammation and protect cells using a pathway that involves
antioxidant properties. There is no generic version available.
Treatment: Oral capsule (120 mg) two times a day for seven days, followed by one 240 mg capsule twice daily.
Side effects: Tecfidera may decrease a person’s white blood cell count and increase the risk of infection. The FDA recommends
that doctors monitor a patient’s white blood cell count annually. Common side effects include:

flushing and redness

diarrhea

itching

rash

nausea
More serious potential side effects include:
PML:
PML is a rare but often fatal brain infection, which is caused by the JCV virus. It usually occurs only in people who are
immunocompromised or being treated with immune suppressing drugs.
Reduced white blood cell count:
A reduced white blood cell count could increase the risk of infections.
Anaphylaxis or angioedema:
Serious allergic reaction, swelling, and difficulty breathing.
Results: In two clinical trials Tecfidera treatment resulted in fewer MS relapses compared to people taking placebo. This included
a 49 percent reduction in relapse compared to placebo in one trial, according to the product’s prescribing information.
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