Expert Tips for Navigating MS Treatments

1. There are many treatments for relapsing MS. How do I know I'm taking the right one?

If you're no longer experiencing relapses, your symptoms aren't getting worse, and you don't have side effects, the treatment is likely right for you.

Depending on the therapy, your neurologist may perform tests, including blood tests, to ensure that it remains safe. It may take up to six months for an MS therapy to be effective. If you experience a relapse within this time, this isn't necessarily considered treatment failure.

Contact your neurologist if you experience new or worsening symptoms. You may need to switch medications if you experience treatment-related side effects as well.

2. Are there any benefits of self-injected medications over oral medications or vice versa? What about infusions?

There are two injectable therapies for MS. One is interferon beta (Betaseron, Avonex, Rebif, Extavia, Plegridy). The other injectable treatment is glatiramer acetate (Copaxone, Glatopa). Despite having to inject them, these medications have less side effects than others.

Oral therapies include:

• dimethyl fumarate (Tecfidera)
• teriflunomide (Aubagio)
• fingolimod (Gilenya)
• siponimod (Mayzent)
• cladribine (Mavenclad)

These are easier to take and more effective at reducing relapses compared to injectable therapies. But they may also cause more side effects.

Infusion therapies include natalizumab (Tysabri), ocrelizumab (Ocrevus), mitoxantrone (Novantrone), and alemtuzumab (Lemtrada). These are administered at an infusion facility once every few weeks or months and are the most effective for reducing relapses.

The National Multiple Sclerosis Society provides a comprehensive summary of FDA-approved MS therapies.

3. What are some common side effects of MS treatments?

Side effects are treatment-specific. You should always discuss any potential side effects with your neurologist.

Common side effects of interferons include flu-like symptoms. Glatiramer acetate can cause injection site lipodystrophy, an abnormal accumulation of fat.

Side effects of oral therapies include:

• gastrointestinal symptoms
• flushing
• infections
• liver enzyme elevations
• low white blood cell count

Some infusions can lead to rare but serious risk for infections, cancers, and secondary autoimmune disease.

4. What are the goals of my MS treatment?

The goal of disease-modifying therapy is to reduce the frequency and severity of MS attacks. MS attacks can lead to short-term disability.

Most neurologists believe that preventing MS relapses may delay or prevent long-term disability. MS therapies don't improve symptoms on their own, but they can prevent injury due to MS and allow your body to heal. MS disease-modifying treatments are effective for reducing relapses.

Ocrelizumab (Ocrevus) is the only FDA-approved therapy for primary progressive MS. Siponimod (Mayzent) and cladribine (Mavenclad) are FDA-approved for people with SPMS who have had recent relapses. The goal of treatment for progressive MS is to slow the disease course and maximize quality of life.

Other therapies are used to treat the chronic symptoms of MS, which can make a significant difference in quality of life. You should discuss both disease-modifying and symptomatic treatments with your neurologist.

5. What other medications can my doctor prescribe to treat specific symptoms like muscle spasms or fatigue?

If you have muscle spasms and spasticity, your doctor may screen you for electrolyte abnormalities. Stretching exercises with physical therapy may also help.

If needed, medications commonly used for spasticity include baclofen and tizanidine. Baclofen may cause transient muscle weakness and tizanidine may cause dry mouth.

Benzodiazepines such as diazepam or clonazepam may be useful for phasic spasticity, including muscle tightness that occurs at night. But they may cause drowsiness. If medications don't help, intermittent Botox injections or an intrathecal baclofen pump may be useful.

People who experience fatigue should first attempt lifestyle modifications, including regular exercise. Your doctor may also screen you for common causes of fatigue, such as depression and sleep disorders.

If needed, medications for fatigue include modafinil and amantadine. Or, your doctor may recommend stimulants such as dextroamphetamine-amphetamine and methylphenidate. Speak with your neurologist to find the best treatment for your MS symptoms.

6. What options do I have for financial help?

Work with your neurologist's office to seek insurance approval for all your MS-related diagnostic testing, treatments, and mobility devices. Depending on your household income, a pharmaceutical company may cover the cost of your MS treatment. The National MS Society also offers guidance and counseling for financial assistance.

If you receive care at a dedicated MS center, you may also be eligible for clinical research trials that can help cover the costs of testing or treatment.

7. What steps should I take if my medications stop working?

There are two main reasons you may want to consider another MS therapy. One is if you're experiencing new or worsening neurologic symptoms despite active treatment. The other reason is if you have side effects that make it difficult to continue the current therapy.

Speak with your neurologist to understand if your treatment is still effective. Don't stop a disease-modifying therapy on your own, as doing so might cause a rebound MS attack in some cases.

8. Will my treatment plan change over time?

If you're doing well on a therapy for MS and don't have significant side effects, there's no need to change your treatment plan. Some people remain on the same treatment for many years.

Your treatment may change if you experience worsening neurologic symptoms, develop side effects, or if tests show that it's not safe to continue the treatment. Researchers are actively investigating new treatments. So, a better treatment for you might be available in the future.

9. Will I need any type of physical therapy?

Physical therapy is a common recommendation for people with MS. It's used to speed up recovery after a relapse or to treat deconditioning.

Physical therapists check and treat walking difficulties and challenges associated with leg weakness. Occupational therapists help people regain use of their arms and complete common daily tasks. Speech therapists help people recover language and communication skills.

Vestibular therapy can help people who experience dizziness and imbalance (chronic vertigo). Depending on your symptoms, your neurologist may refer you to one of these specialists.

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Dr. Jia is a graduate of Massachusetts Institute of Technology and the Harvard Medical School. He trained in internal medicine at the Beth Israel Deaconess Medical Center and in neurology at the University of California San Francisco. He is board-certified in neurology and received fellowship training in neuroimmunology at UCSF. Dr. Jia's research focuses on understanding the biology of disease progression in MS and other neurologic disorders. Dr. Jia is a recipient of the HHMI Medical Fellowship, the NINDS R25 award, and the UCSF CTSI Fellowship. Aside from being a neurologist and statistical geneticist, he is a lifelong violinist and served as Concertmaster of the Longwood Symphony, an orchestra of medical professionals in Boston, MA.