Choices
Drug Therapies
There are many prescription drugs available to treat MS. There are disease modifying
drugs that affect the long-term course of MS and other medications to treat a particular
symptom.
Disease Modifying Treatments (DMTs)
There are number of disease-modifying treatments (DMTs) which can reduce the
frequency and severity of clinical relapses.
The National Institution for Care Excellence (NICE) published guidelines in October
2014 for the management of multiple sclerosis. In these guidelines a relapse can be
diagnosed by a GP or neurologist if:
The person with MS has developed new symptoms or has a worsening of existing
symptoms, and these symptoms have lasted for more than 24 hours in the absence of
infection of any other cause after a stable period of a least 1 month.
The following DMTs are available for treatment of relapsing remitting multiple sclerosis,
CIS and secondary progressive MS who are still experiencing relapses, and where
these relapses are the predominant cause of their increasing disability :Avonex - a weekly injection into the muscle.
Rebif – an injection three times a week subcutaneously (under the skin).
Betaferon – an injection every other day subcutaneously (under the skin).
Extavia – an injection every other day subcutaneously (under the skin).
Glatiramer acetate (Copaxone) - a daily injection subcutaneously (under the skin).
The following DMTs are additionally available for treatment of relapsing remitting
multiple sclerosis:
Fingolimod (Gilenya) - an oral tablet taken once a day.
Tecfidera (Dimethyl fumerate) - an oral tablet twice a day.
Teriflunomide (Aubagio) - taken orally once a day.
For more detailed information about DMTs, please see our Choices leaflet ‘Disease
Modifying Treatments.
Tysabri (Natalizumab)
A monoclonal antibody that works in a different way to the above DMTs, by preventing
immune cells leaving the blood stream and entering areas of inflammation.
This is available for people on the NHS with rapidly evolving, severe relapsing remitting
MS. Rapidly evolving, severe RRMS is defined by two or more disabling relapses in
one year along with an increase of lesions as shown on an MRI.
Tysabri is a once a month intravenous infusion into a vein over a one hour period in a
registered infusion facility.
For more detailed information about Tysabri, please see our Choices leaflet ‘Tysabri’.
Alemtuzumab (Campath/Lemtrada)
Alemtuzumab was originally licensed for the treatment of leukaemia. It is an anti-CD52
monoclonal antibody which kills T-cells, a type of lymphocyte involved in the MS
immune response. It basically ‘reboots’ the immune system. Once the t-cells are killed
(lymphocytes) the system then repopulates, leading to a modified immune response
that no longer regards myelin and nerves as foreign.
The drug received NICE appraisal as an NHS treatment in May 2014 from NICE and in
July 2014 from the Scottish Medicines Consortium (SMC).
Other Drugs used in MS
Low Dose Naltrexone (LDN)
LDN has been used in the treatment of MS in the USA since 1985 but it is relatively new
in the United Kingdom. Naltrexone is a drug referred to as an opiate antagonist. Its
normal use is to treat opiate drug addicts addicted to drugs such as heroin; however
when taken to treat MS, the dose is much smaller. Those taking it have experienced a
range of benefits, including reduced spasm and fatigue, improvements in bladder
control, heat tolerance, mobility, sleep, pain, tremor and other symptoms. The two main
symptoms that appear to improve most significantly are muscle spasm and fatigue.
It is not recognised by the NHS as a proven treatment for MS symptoms and may not
therefore be prescribed by a GP or neurologist easily. It can be purchased privately in
the UK.
For more information about LDN, please see our Choices leaflet ‘LDN’.
Mitoxantrone (Novantrone)
Licensed in the UK as a form of chemotherapy used in cancer treatment but can be
used to treat some forms of MS. Usually given to people who have not responded to
Copaxone or any of the Interferons. It is given at the Neurologist’s discretion by
intravenous infusion.
Steroids
Steroids are sometimes used when a person experiences a relapse to help speed
recovery. Steroids can reduce inflammation in the CNS. They are usually administered
intravenously but sometimes orally. In short term use, side-effects are usually minor.
Long term use should be avoided as this can cause many side-effects including weight
gain, acne and cataracts. For this reason, NICE guidelines recommend only using
steroids three times a year.
Fampridine (Fampyra/Ampyra)
This drug therapy is a formulation of 4-aminopyridine – a potassium channel blocker. It
is thought that it can enhance the conduction of messages in damaged nerve fibres by
blocking potassium leaks. It is generally prescribed for people with MS who have MS
related mobility problems. Taken twice a day, fampridine is a licensed treatment to
improve walking speed.
Fampridine is not recommended by the Scottish Medicines Consortium (SMC).
In October 2014 the National Institute of Care Excellence published clinical guidelines
for the treatment of multiple sclerosis. In these guidelines, NICE states that fampridine
should not be offered to treat a lack of mobility in people with MS. This recommendation
does not apply to people who have already started treatment with fampridine in the NHS
who should be able to continue treatment until they and their NHS clinician think it
appropriate to stop.
Drugs in development and trial
The average time it takes for a new compound to get from the test tube to be licensed is
10 to 15 years. It is important to remember that not all these drugs will complete the
development process and be licensed for general use or be recommended by NICE
(National Institute for Health and Care Excellence) or the SMC (Scottish Medicines
Consortium)
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ATX-MS-1467
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Daclizumab
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Masitinib
Ocrelizumab
Ofatumumab
Tovaxin
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Laquinimod
Natalizumab
Siponimod
Drugs used to manage symptoms
Bladder Dysfunction – see our Choices leaflet ‘Bladder & Bowel’ for further
information.
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Oxybutynin
Oxybutynin is used to control urgent, frequent, or uncontrolled urination in people
who have overactive bladder (a condition in which the bladder muscles have
uncontrollable spasms) or other conditions that affect the bladder muscles.
Oxybutynin is in a class of medications called anticholinergics. It works by
relaxing the bladder muscles to prevent urgent, frequent, or uncontrolled
urination.
Desmopressin
Desmopressin is a synthetic antidiuretic hormone, which basically means that it
supresses the production of urine in the kidneys by up to 8 hours. It is used to
help relieve urinary incontinence in conditions such as MS. More specifically, it is
used for those who experience ‘nocturia’, the need to frequently go to the toilet at
night.
It can also be used during the day if finding a toilet may be difficult. For example,
on a long journey. It should not be over-used due to the dangers of retaining too
much urine.
Detrusitol (Tolterodine)
Tolterodine is used to relieve urinary difficulties, including frequent urination and
inability to control urination. Tolterodine is in a class of medications called
antimuscarinics. It works by preventing bladder contraction.
Botox
Botulinum toxin type A (Botox) is best known as a cosmetic treatment for facial
wrinkles. Doctors have also found that botulinum toxin is useful in blocking
spasms like eye ticks or relaxing muscles in patients with multiple sclerosis.
Urologists have found that injecting botulinum toxin into the tissue surrounding
the sphincter can help it to relax. Botox for the bladder was approved by the
MHRA in September 2012 for those who have failed on existing treatments such
as anticholinergics.
Fatigue – see our Choices leaflet ‘Fatigue’ for further information.
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Amantadine
Amantadine is used to treat Parkinson's disease and conditions similar to those
of Parkinson's disease. This medication is sometimes prescribed for other uses
such as fatigue in multiple sclerosis.
Spasticity - see our Choices leaflet ‘Symptoms’ for further information.
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Baclofen
Baclofen acts on the spinal cord nerves and decreases the number and severity
of muscle spasms caused by multiple sclerosis or spinal cord diseases. It also
relieves pain and improves muscle movement.
Dantrolene
Dantrolene is used to treat chronic (long-term) muscle spasm or spasticity. Longterm muscle stiffness can occur in multiple sclerosis and other conditions where
there has been damage to the nerves that supply the muscles. In these cases,
muscles may contract (or shorten) tightly, they can then become stiff and harder
to use. This is called spasticity.
Dantrolene works by relaxing the muscles and preventing spasms. This helps to
reduce any pain and discomfort.
Diazepam
Diazepam is a type of medicine called a benzodiazepine. Benzodiazepines are
used for their sedative, anxiety-relieving and muscle-relaxing effects.
Diazepam works by acting on receptors in the brain called GABA receptors. This
causes the release of a neurotransmitter called GABA in the brain.
Botox
See above
Tizanidine (Zanaflex)
Zanaflex tablets contain the active ingredient tizanidine, which is a type of
medicine known as an alpha-2-adrenoceptor agonist. Tizanidine is used as a
muscle relaxant, in conditions such as multiple sclerosis and spinal cord injury or
disease.
Sativex
Sativex is a cannabis-based medicine used by people with MS for spasticity,
when first line drugs have been ineffective or where side effects of those drugs
are intolerable. It is an oral-mucosal spray into the mouth, under the tongue or
inside of the cheeks. The number of sprays or timings of these sprays varies
dependent on severity of symptoms and will be confirmed by the prescribing
doctor. The maximum number of sprays a day is 12 and a gap of at least 15
minutes should be left between sprays. The most common side effects are
dizziness, fatigue, drowsiness and nausea.
In October 2014 the National Institute of Care Excellence published clinical
guidelines for the treatment of multiple sclerosis. In these guidelines, NICE states
that Sativex should not be offered to treat spasticity in people with MS.
Sativex may still be available through the NHS if funding is secured through an
Individual Funding Request, although such a request is less likely to be
successful in the light of the NICE guidelines.
Sativex can be purchased privately if a private prescription is obtained from a
GP.
Tremor – see our Choices leaflet on ‘Symptoms’ for further information.
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Propranolol
Syprol oral solution contains the active ingredient propranolol, which is a type of
medicine called a beta-blocker. Beta-blockers work by blocking beta receptors
that are found in various parts of the body. Blocking beta receptors prevents the
action of two chemicals, called noradrenaline and adrenaline, which are
produced naturally by the body. Beta-blockers may have some effect on reducing
MS related tremor.
Primidone (Mysoline)
Primidone is a medicine which is used in partial epilepsy, generalised epilepsy,
myoclonus and essential tremor. Mysoline tablets contain the active ingredient
primidone.
Clonazepam (Rivotril)
Rivotril tablets and injections both contain clonazepam, which is a type of
medicine called a benzodiazepine. Clonazepam is also available without a brand
name, i.e. as the generic medicine. Clonazepam acts on nerve cells in the brain.
Clonidine
Clonidine is thought to reduce the responsiveness of small blood vessels to
stimuli which would normally make them contract (narrow) or dilate (widen). This
prevents the changes in the blood vessels of the brain which are associated with
migraine, and thus prevents attacks.
Pain – see our Choices leaflet on ‘Pain’ for further information.
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Gabapentin
The way in which gabapentin works is not fully understood. It is thought to work
by binding to calcium channels found on nerve cells in the brain and spinal cord.
This is thought to affect the release of various neurotransmitters from these
nerve cells.
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Pregabalin
The way in which pregabalin works is not fully understood. It is thought to work
by binding to calcium channels found on nerve cells in the brain and spinal cord.
This reduces the release of various neurotransmitters from these nerve cells.
Carbamazepine
Carbamazepine is an anticonvulsant. It works by decreasing nerve impulses that
cause seizures and pain. Carbamazepine is used to treat seizures and nerve
pain such as trigeminal neuralgia and diabetic neuropathy. It is also used to treat
bipolar disorder.
Amitriptyline
Amitriptyline is a tricyclic antidepressant. It affects chemicals in the brain that
may become unbalanced. Amitriptyline is used to treat symptoms of depression.
Duloxetine
Duloxetine is a serotonin-norepinephrine reuptake inhibitor, affecting chemicals
in the brain that may be unbalanced. Duloxetine is used to treat symptoms of
depression and generalised anxiety disorder, but can relieve the symptoms of
neuropathic pain.
Erectile Dysfunction – see our Choices leaflet on ‘Sexual Dysfunction’ for further
information.
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Cialis
Cialis (Tadalafil) relaxes muscles and increases blood flow to particular areas of
the body. Cialis is used to treat erectile dysfunction (impotence) in men.
Viagra
Viagra (sildenafil) relaxes muscles and increases blood flow to particular areas of
the body. Viagra is used to treat erectile dysfunction (impotence) in men.
Levitra
Levitra (Vardenafil) is a phosphodiesterase inhibitor. It works by helping to relax
muscles and increase blood flow into the penis during sexual stimulation. This
helps men to achieve and maintain an erection. Levitra is used to treat erectile
dysfunction (impotence).
Updated October 2014