MS Medications

There is no magic pill that cures MS or relieves all of its symptoms; Frown but there are different medications and therapies, which lessen many symptoms, shorten attacks, and may slow down the expected slow and ongoing progression of Multiple Sclerosis. Happy Smiley

  1. Interferons
  2. Copaxone
  3. MonoClonal AntiBodies

  1. Avonex
    Slows the accumulation of physical disability and decrease the frequency of clinical exacerbations, in Relapsing forms of Multiple Sclerosis. The dose is 30 mcg, taken once a week and over two years reduced disability progression by 37%.

  2. Rebif
    Is chemically identical to Avonex, but Rebif is injected subcutaneously, in a larger dosage (44 mcg three times per week) and reduced the relapse rate by 32% in the PRISMS study.

  3. Betaseron
    Reduces the frequency of clinical exacerbations, in ambulatory, Relapsing/Remitting MS. The dose is 8 MIU, taken every other day and reduced the relapse rate by 33%.

  4. Extavia
    Extavia is an Interferon-beta-1b that is biologically identical to Betaseron and made in an identical process, but marketed by a different company. It was released in early 2010.

    Extavia shares all prescribing, side effect, and safety information with Betaseron. The two pharmaceutical companies manage their patient support programs differently; prices and copayments also may vary.

    The latest information is available through the patient support programs at these two companies.

    Administered by subcutaneous injection every other day; dose is 250 mcg. The same medicinal product as Betaseron®, Extavia offers patients and physicians a new branded version of Interferon-beta-1b.

    Extavia is approved by the FDA for the treatment of Relapsing forms of MS to reduce the frequency of clinical exacerbations. Extavia has been shown to reduce annualized relapse rates by 34% [Neurology 1993;43:655-661].

    The therapy is also indicated for patients who have experienced a first clinical episode of MS (CIS) and have features consistent with the disease as shown by Magnetic Resonance Imaging (MRI).

  5. Copaxone
    Decreases the frequency of clinical exacerbations, in Relapsing/Remitting Multiple Sclerosis. The dose is 20mg, taken every day and reduced the relapse rate by 29%.

  6. Tysabri (Natalizumab)
    Is a MonoClonal AntiBody bioengineered from part of a mouse AntiBody to closely resemble the human AntiBody. It is given intravenously once a month in a physician's office. Tysabri reduced the frequency of relapses by 66% relative to placebo.

    Common adverse reactions include Urinary Tract, Lower Respiratory Tract, GI System, and Vaginal Infections, Headache, Depression, Joint Pains, and Menstrual Disorders.

    The rate of Progressive Multifocal Leukoencephalopathy (PML) increases with the length of time a patient remains on the drug. The incidence of PML in patients taking Tysabri for roughly a year is 0.01 per 1,000 patients.

    That rate rises to 0.35 cases per 1,000 in patients taking the drug for between one and two years, and to 1.47 cases for patients taking it between two and three years.

  7. Gilenya (Fingolimod)
    The FDA has approved Gilenya for the treatment of adults with Relapsing forms of MS. Gilenya (Fingolimod) is taken once a day orally, rather than by injection or infusion, and its mode of action is unique.

    Gilenya binds to a docking site (Sphingosine-1-Phosphate Receptor, or S1P Receptor) on Immune Cells, including T-Cells and B-Cells that have been implicated in causing Nervous System damage in MS.

    The drug appears to force some Immune Cells to remain in Lymph Nodes, and inhibits them from migrating into the Brain and Spinal Cord. Gilenya reduced the frequency of relapses by 54% with the lower dosage vs a 60% reduction for the higher dose relative to placebo. [N Engl J Med 2010; 362:387-401]

Steroid Regimes

    Steroids Have Two Different Mechanisms:
      • They decrease AntiBody production
      • They reduce Myelin Swelling & Inflammation
They improve Nerve Conduction in the DeMyelinated area, through both diverse Hormonal & Chemical changes, such as increasing the nerve cell's Potassium levels while decreasing Sodium.   (Also See: Steroids)

ACTH (AdrenoCorticoTrophic Hormone)
A short term, anti-inflammatory agent. Short term therapy carries little risk and reduces the length and severity of most acute attacks. The long term use of ACTH does not alter the course of MS and is hazardous.

Solu-Medrol® (MethylPrednisolone)
A Steroid that is given IntraVenously in large doses over a four-to-six day period. You may receive Solu-Medro® in the hospital - to be monitored for adverse side effects - or in your home with a visiting nurse administering the IV drug.

Early in the course of MS, Solu-Medrol generally helps stabilize or improve symptoms; however, over time Steroids become less and less effective.

It is very important that you personally realize, Steroid's short-term benefits must be weighed against its negative, long-term and permanent costs; you and your family will bear these future costs, not your doctor. Frown

Steroid's Short-term Side-Effects
Include Stomach Upset, Mood Swings, Insomnia, Headache, Acne, Nervousness, and Bloating. These are reversible and usually disappear, after the medication is stopped.

Long-Term Risk
Of Infection, Bone Degeneration, Osteoporosis, Cataracts, Increased susceptibility to all infections, and Impaired healing process.

Common Side-Effects
When CorticoSteroid use is moderate or prolonged (the typical dosages used in MS treatments):
  • Yeast and Fungal Infections
  • Cushing's Syndrome
  • Blurred vision from Cataracts
  • Glaucoma
  • Fractures & Osteoporosis, most often in the Hip & Spine
  • Vascular Necrosis, most often in the Hip or Shoulder
  • Severe Weakness of the Muscles [Myopathy]
  • Psychosis, which is a severe disturbance of thinking
  • Serious Infections, from suppressing the Immune System

Withdrawl Warning
CorticoSteroid withdrawal can induce mental disturbances. Because of its euphoric effect, it is likely you will become psychologically dependent on CorticoSteroids; ironically, Depression, Agitation, Anxiety, and Psychotic reactions are also seen during withdrawal.

Prednisone (Deltasone®), Prednisolone (Delta-Cortef®), Medrol®, & Decadron® (Dexamethasone)
Are Synthetic Steroids that are given orally to shorten acute MS exacerbations.

Oral Steroids are also prescribed after Solu-Medrol® treatment, to gradually wean the body from the medication and allow the Adrenal Glands to resume normal functions. Suddenly stopping Steroids can cause renewed MS symptoms (rebound symptoms).

Side-Effects
From Oral Steroids are similar to those from Solu-Medrol®. Most research indicates Oral Steroids should NOT be taken for Optic Neuritis.

Symptom Management

  • Bladder

  • Depression

  • Fatigue

  • Pain

  • Spasticity

  • Tremors

  • Vertigo

  • Walking
    		•

    Symptomatic treatment can be a delicate balance, as many drugs can cause Side-Effects which mimic MS symptoms.

    A drug taken to decrease pain, for example can cause Bladder difficulties. Medication is only part of the total treatment plan.

    Physical, Occupational, Speech and Psychological therapies, along with changes in Diet and Lifestyle, may help improve your functioning abilities.

    In many cases, therapies can enhance the effect of medication, your physician should always be informed of all your treatments and therapies.

    Bladder Control

    DDAVP ® (Desmopressin)
    A synthetic Hormone (Arginine Vasopressin regulations Blood Pressure, Stomach & Intestinal movements, Uterine & Kidney Functions), used as a nasal spray, it works on the Kidneys to control Frequent Urination.

    Common Side-Effects: an increase in Blood Pressure, Runny or Stuffy Nose, Abdominal or Stomach Cramps, Flushing of the Skin, Headache, Nausea, and Pain in the Vulva.

    Unusual Side-Effects that require immediate medical attention: Confusion, Convulsions, Unusual Drowsiness, Continuing Headache, Rapid Weight Gain, and Markedly Decreased Urination.

    Detrol® (Tolterodine Tartrate)
    An effective, well-tolerated medication for the treatment of Overactive Bladder. A medical condition whose symptoms of Urinary Frequency, Urgency or Urge Incontinence negatively affect quality of life.

    Side-Effects
    Are considered to be treatment related: Dry Mouth 59.5%, Dyspepsia 5.9%, Headache 11.0%, Constipation 6.5%, and Xerophthalmia (Vitamin A Deficientcy) 3.8%.

    Dibenzyline® (Phenoxybenzamine)
    A drug which Relaxes the Sphincter Muscle of the Bladder to relieve functional obstruction of Urinary Outflow. A major Side-Effect is Low Blood Pressure when the person is standing.

    Ditropan XL® (Oxybutynin Chloride)
    A once-daily drug therapy for Overactive Bladder, it is reported to be superior to placebo in terms of reduction in Urge Incontinence episodes experienced per week, with recipients experiencing about 15-18 fewer episodes per week.

    The most common Side-Effects are: Dry Mouth 61%, Constipation 13%, Drowsiness 12%, Diarrhea 9%, Blurred Vision 8%, Dry Eyes 6%, Dizziness 6%, & Runny Nose 6%.

    Hytrin® (Terazosin Hydrochloride)
    An alpha-1-selective Adrenoceptor blocking agent. It is a Quinazoline derivative used to treat Bladder outlet obstruction (hesitant Bladder), without affecting Bladder contractility. Terazosin relaxes smooth muscles in the Bladder-Neck; without affecting the Bladder-Body, where there are fewer alpha-1-selective Adrenoceptors.

    The most common Side-Effects are: Syncope (Hypotension), Dizziness 9.1%, Asthenia 7.4%, Nausea 4.4%, Postural Hypotension 3.9%, Lightheadedness, Somnolence 3.6%, Nasal Congestion/Rhinitis 1.9%, Impotence 1.6%, and Vertigo 1.4%.

    Terazosin is Contraindicated with other AntiHypertensive agents, especially the Calcium Channel Blocker Verapamil    ®.

    Pro-Banthine® (Propantheline), Ditropan® (Oxybutynin), Cystopas® & Urispas® (Hyoscyamine Sulfate)
    Are AntiCholinergic drugs that reduce Smooth Muscle Spasms in the Bladder and promote Bladder filling. People with Glaucoma are not to use and caution needs to be used if these drugs are taken in the presences of high environmental temperature - Heat Prostration can occur.

    Tegretol® (Carbamazepine)
    An AntiConvulsant that stops Incontinence, when it is caused by DeMyelination in the Pontine Micturition Center.
    (See: Incontinence abstract)

    Side-Effect: Rashes, Weakness, Drowsiness, & Aplastic Anemia. Low blood cell counts are a rare but possible Side-Effect.

    Tofranil® (Imipramine)
    A TriCyclic AntiDepressant used to treat mental Depression. Its primary use in Multiple Sclerosis is to treat Bladder symptoms, including Urinary Frequency and Incontinence. Imipramine is also prescribed occasionally for the management of Neurologic Pain in MS.

    Side-Effects: Dry Mouth, Drowsiness, Increased Sensitive to Sunlight, Headache; Decreased Sexual Ability, Increased Appetite, Nausea, Unusual Tiredness or Weakness, Unpleasant Taste, Diarrhea, Heartburn, Increased Sweating, vomiting.

    Depression

    Aventyl®, Pamelor® (Nortriptyline)
    A Selective Serotonin ReUptake Inhibiter (SSRI), not a MonoAmine Oxidase Inhibitor. It inhibits the activity of the NeuroTransmitters: Histamine, 5-Hydroxytryptamine (Serotonin), & Acetylcholine.

    It increases the effect of NorEpinephrine but blocks the response of Phenethylamine. Nortriptyline interferes with the transport, release, and storage of Catecholamines. It is similar to Amitriptyline, but its onset of action is milder and also works to improve Mood while decreasing Insomnia and Pain.

    Elavil® (Amitriptyline)
    And other Tri-Cyclic AntiDepressants have a long biological half-life, therefore it takes about two weeks to accumulate in the body before its concentration becomes stable. Side-Effects include Dry Mouth, Constipation, and Bladder Hesitance.

    Prozac® (Fluoxetine)
    Has different side effects than Elavil and the therapeutic benefits are sooner. The dry mouth and sedation that accompany Elavil disappear with Prozac.

    Side-Effects: include Anxiety, Dry Mouth, Nervousness, Somnolence, Insomnia, Tremors, Diarrhea, Dizziness and Light Headiness.

    Tofranil® (Imipramine)
    A Tri-Cyclic AntiDepressant which has the same actions and side effects as Elavil. It is only administered once a day because of its long duration of action.

    Fatigue (Lassitude)

    Amantadine (Symmetrel®)
    Is used to treat chronic fatigue, the most common MS symptom. An AntiViral medication used to prevent or treat Influenza, it effectively relieves fatigue, in about 33% of the people who try it. Amantadine facilitates the release of Dopamine (a NeuroTransmitter) from CNS Nerves.

    Side-Effects of Amantadine include: Increased Spasticity, Insomnia, Tingling Hands and Feet, and Sleep Disorders.

    Cylert® (Pemoline)
    A CNS stimulant with minimal Sympathomimetic effects, it is taken once a day. Studies indicate Cylert may act through Dopaminergic mechanisms.

    Insomnia is the most frequently reported Side-Effect; usually early in therapy, prior to an optimum therapeutic response. In the majority of cases it is transient or responds to a reduction in dosage.

    Special Notice - FDA 6-18-99
    Liver function tests [Serum ALT (SGPT) levels], should be determined at baseline and continued periodically (every two weeks) thereafter. Additionally, a patient information/consent form must be signed; because of its association with life threatening hepatic failure.

    Cylert should not ordinarily be considered as first line drug therapy. Decreased Seizure threshold has been reported, when receiving Cylert concomitantly with AntiEpileptic medications.

    Provigil®, Alertec® (Modafinil)
    A wakefulness-promoting drug that is orally administered; it is indicated to improve wakefulness in patients with excessive daytime sleepiness associated with Narcolepsy. The dosage is 200 - 400 mg/day, either in a single dose or split in half and taken in the morning and at noon.

    Modafinil binds to the Dopamine reuptake site, causing an increase in ExtraCellular Dopamine, but no increase in Dopamine release. Modafinil promotes wakefulness through unknown mechanisms.

    It is listed in Schedule IV of the Controlled Substances Act and produces psychoactive and Euphoric effects, alterations in Mood, Perception, Thinking and Feelings typical of other CNS stimulants.

    The major route of elimination (~90%) is metabolism, primarily by the Liver, with subsequent renal elimination of the metabolites.

    Side-Effects include Headache, Infection, Nausea, Nervousness, Anxiety, and Insomnia. Physicians should follow patients closely, especially those with a history of drug and/or stimulant (e.g., Methylphenidate, Amphetamine, or Cocaine) abuse. Patients should be observed for signs of misuse or abuse (e.g., incrementation of doses or drug-seeking behavior).

    Prozac® (Fluoxetine)
    Has also been found to be an effective treatment for MS Lassitude (Fatigue).

    Side-Effects include Anxiety, Dry Mouth, Nervousness, Insomnia, Somnolence, Tremors, Diarrhea, Dizziness and Light Headiness.

    Ritalin® (Methylphenidate)
    A Central Nervous System stimulant that is used to treat Attention Deficit Disorder and Narcolepsy in the general population. It may be useful in treating fatigue in MS patients yet it is highly addictive and chronically abusive use can lead to marked tolerance and psychological dependence.

    Pain

    Most of the Pain experienced in MS is called Neurogenic or Central Pain.

    Unlike the *Pain* (Nociceptive Pain) most people know, Neurogenic Pain does NOT follow Peripheral and Central Pain Pathways and does NOT Respond to the administration of conventional Analgesics, including Opiates, which act at the Synapses of the Classic Pain Pathway.

    These widely known and IMO, *mis-labled* Anti-Depressants (Tri-Cyclic Compounds) are the most effective means to relieve Neurogenic Pain (Central Pain).

    Tri-Cyclic compounds block the reuptake of Serotonin, a NeuroTransmitter which enhances Pain Inhibition in the CNS's Descending Pathways (Limbic System).

    This action increases the avilability of Serotonin for the Higher Brain's use in Nerve transmissions.

    Dilantin® (Phenytoin)
    Another AntiConvulsant that is useful for relieving Pain associated with irritating Sensory Loss. It is less effective than Tegretol and also less toxic, but blood tests should also be obtained prior to therapy.

    A total dose of 300 mg is the goal, or until partial pain relief is obtained, and then carefully titrate the dose upward. Blood levels should be obtained pre-treatment, and Side-Effect are similar to Tegretol.

    Elavil® (Amitriptyline)
    Or its milder *cousin* Nortriptyline, and other Tri-Cyclic AntiDepressants are useful in the treatment of Involuntary Facial Movements, Painful Pins & Needles Feelings, and Emotional Outbursts.

    Side-Effects: include Dryness of the Mouth, Constipation, and Bladder Hesitancy.

    Naprosyn
    A Non-Steroidal Anti-Inflammatory, like Motrin and Clinoral, that are useful in reducing Pain and Inflammation. Continuous use at high doses could lead to Gastrointestinal Tract Ulceration and Bleeding.

    Neurontin® (Gabapentin)
    A new AntiConvulsant that has shown some promise in the treatment of Neuropathic pain. It may be the next reasonable step for those patients not adequately treated with Tegretol or Dilantin.

    The drug is increased in 300 mg increments over two days as side-effects allow, until a total dose of 1800 mg daily is reached. Daily dose should not exceed 2400 mg.
    Side-Effects: Sedation, Dizziness, & Confusion.

    Tegretol® (Carbamazepine)
    An AntiConvulsant that relieves pain arising in the Nervous System. Especially helpful in Tic Douloureux.

    Start with a 100-200 mg dose of Tegretol at bedtime for two nights and caution the patient regarding Side Effects, including Dizziness, Sedation, Confusion, and Rash.

    The drug is in equally divided doses over two days, as Side-Effects allow, until pain relief is obtained or a total dose of 1200 mg daily is reached.

    Careful monitoring of lab parameters is mandatory to avoid the rare possibility of life-threatening Blood Dyscrasia. At the first sign of blood count abnormality or rash, Tegretol should be discontinued.

    Failure to monitor patients started on Tegretol can be disastrous, as Aplastic Anemia can occur. When pain relief is obtained, the patient should be kept at that dosage at least six months before tapering. Routine Hematologic monitoring after stable dosage is reached is unnecessary.

    Tegretol blood levels should be obtained when non-compliance is suspected, when Side-Effect occur at doses under 1200 mg, and when a 1200 mg/day dose is reached, to establish a baseline to allow safe titration of the dosage upward.

    Side-Effect: Rashes, Weakness, Drowsiness, & Aplastic Anemia. Low blood cell counts are a rare but possible Side-Effect.

    Spasticity

    Clonidine® (Catapres-TTS)
    Stimulates alpha2-AdrenoReceptors in the BrainStem, resulting in reduced Sympathetic outflow from the Central Nervous System and a decrease in peripheral Blood Vessel Resistance, Renal Vascular Resistance, Heart Rate, and Blood Pressure - it is an AntiHypertensive agent. Some find Clonidine is helpful for Spasticity.

    Common Side-Effects: are Low Blood Pressure 45%, Dizziness 13%, Anxiety 11%, and Dry Mouth 13%.

    Dantrium® (Dantrolene)
    Is recommended only for Spasticity that does not respond to Lioresal (Baclofen). Brief withdrawal for a period of 2-4 days will result in exacerbations of Spasticity. Long term therapy must meet specific criteria.

    Dantrolene is a Muscle Relaxant for relief of the Cramping, Spasms and Tightness of Muscles caused by Multiple Sclerosis. It acts directly on the Muscles.

    Side-Effects may include Liver toxicity especially among people who use more than 100 mg per day. Dantrium therapy may cause several Liver Disorders (Fatal and Non-Fatal).

    Adverse-Reactions commonly include: Drowsiness, Dizziness, Weakness, General Malaise, Fatigue and an Increase in Photosensitivity.

    Lioresal® (Baclofen)
    Is given to treat stiffness or Spasticity, the second most common symptom of MS. It can often improve and relive painful Sensory disturbances.

    Careful monitoring of lab values is indicated during the initial use of the drug. In treating patients with any of these drugs, the premature tapering or discontinuation of the medication may lead to the recurrence of pain and it will be more difficult to control pain thereafter.

    Baclofen has significant Hepatic and Central Nervous System Side-Effects: Increasing Muscle Weakness, Sedation, and Confusion are most common; for these reasons.

    It is poorly tolerated by many people and dosages must be slowly lowered before discontinuing its use, since suddenly stopping it, may induce Hallucinations and Seizures.

    Valium® (Diazepam)
    Is a Benzodiazepine derivative classified as an AntiAnxiety drug that can also be used to help relieve Spasticity. Diazepam appears to act on parts of the Limbic System: the Thalamus & HypoThalamus, inducing a calming effect.

    Side-Effects: Drowsiness, Fatigue, and Ataxia. Valium may be addictive.

    Zanaflex® (Tizanidine)
    Is an alpha2-Adrenergic Agonist (like Clonidine), it is a short-acting drug for management of Spasticity's increased muscle tone. The reduction of muscle tone has its peak effect 1 to 2 hours, and the benefit dissipates in 3 to 6 hours.

    Side-Effects: Tizanidine can produce Hypotension (Low-Blood Pressure), Bradycardia, Light-Headedness/Dizziness and rarely, Syncope.

    Common Side-Effects: Sedation, Dry Mouth (49%), Somnolence (48%), Asthenia [Weakness, Fatigue and/or Tiredness (41%)], and Dizziness (16%).

    UnCommon Side-Effects: Tizanidine may causes Liver Injury, Nausea, Vomiting, Anorexia, Jaundice, Hallucinosis, and Delusions.

    Tremors

    Klonopin® (Clonazepam)
    Exhibits several pharmacologic properties which are characteristic of the Benzodiazepine class of drugs. Clonazepam can provide some relief from Tremors. It is Very Sedating, producing CNS Depression, so it is useful in just small numbers of patients.

    Vertigo & Dizziness

    Antivert® (Meclizine)
    Helps manage Nausea, Vomiting and Dizziness associated with Motion Sickness and is used in the management of Vertigo that some experience in MS.

    Side-Effects include Drowsiness, Dryness of the Mouth, and rarely Blurred Vision.

    Diminhydrinate
    Is a similar drug related to Benedryl® (Diphenhydramine) that is also used; it inhibits Acetylcholine one of the best known NeuroTransmitters in the Brain.

    Transderm Scop® (Scopolamine)
    Is an AntiCholinergic drug that helps treat Dizziness, it is a skin patch that lasts for several days.

    Potential Adverse-Effects: Confusion, Memory Disturbances, Drowsiness, and Dryness of the Mouth.

    Walking (Gait)

    Amypra® (Dalfampridine)
    Extended Release Tablets is indicated as a treatment to improve walking in patients with Multiple Sclerosis (MS). This was demonstrated by an increase in walking speed. Amypra is a tablet, taken twice a day about 12 hours apart.

    Ampyra is a broad-spectrum Potassium Channel Blocker, and the first MS medication to enhance Impulse Conduction in the nerve fibers whose insulating Myelin layer has been damaged, by blocking some of the Potassium Ion Channels.

    Ampyra is thought to block Potassium (K+) Channels. This can make a difference for some people with MS. Ampyra does not replace Potassium, nor is it a Potassium supplement.

    It is not known if Ampyra is safe and effective in children less than 18 years of age.
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    Side-Effects
    Do not take Ampyra if you: have ever had a Seizure, it may cause serious side effects, including Kidney or Bladder infections. Your chance of having a Seizure is higher if you take too much Ampyra or if you have Kidney problems.

    The most common side effects of Ampyra include: Urinary Tract Infection; trouble Sleeping (Insomnia); Dizziness; Headache; Nausea; Weakness; Back Pain; problems with balance; Multiple Sclerosis relapse; burning, tingling or itching of your skin; irritation in your nose and throat; constipation; indigestion; pain in your throat.

    If you are taking any of the medications mentioned above, or any other drug, it is important you know all of their possible Side-Effects.

    Full complete disclosure is your medical right and it must be provided, in plain, understandable English.

    You are the only person who will live with the consequences of your choice in treatment options.

    Use this time to research all MS medications and do not accept any medication you do not understand or feel comfortable using.

    You should know how much medication to take and when you may run into trouble, if you discontinue or change the dosage. A drastic or abrupt change of some medication can have severe adverse effects.

    Multiple Sclerosis is an uniquely individual disease; what works for someone else may not be effective for you. The key to effectively using any medication is to be informed of its risks and benefits.

    Always consult your physician about your health concerns, MS symptoms, and weigh the drug's benefits against its Long-Term Side-Effects.

    This Information is offered as general information and is not meant to replace consultation with your physician.

    To your health,                 
    Thomas J. Copeland Jr.
    <tjc@thjuland.net>        

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