Reviewing the Options for Treating MS

Steroids for multiple sclerosis patients still appear effective but potentially less harmful medications may be an option

/ Author:  / Reviewed by: Robert Carlson, M.D Beth Bolt, RPh

(RxWiki News) Multiple sclerosis (MS) symptoms vary widely among those with the disease. And that can complicate efforts to prescribe the right treatment for MS patients.

A steroid called methylprednisolone is commonly used to treat the extreme fatigue, lack of mobility and other symptoms of MS and remains the most effective treatment, according to a new analysis.

But steroids can have serious side effects. The same analysis concluded that other kinds of medications--some with milder side effects and some with severe side effects--may be treatment options for certain patients.

"Ask your doctor about the best treatment for multiple sclerosis."

This study’s lead author was Loredana La Mantia, MD, of Cochrane Multiple Sclerosis and Rare Diseases of the Central Nervous System Group in Milan, Italy.

For this investigation, Dr. La Mantia and her team of researchers reviewed results from several clinical trials of steroids and of other medications that either have been approved and prescribed to treat multiple sclerosis or are under investigation as a treatment option.

These researchers also investigated the benefits and risks of those various treatments.

Dr. La Mantia and colleagues noted that potential side effects of steroid use include diabetes, high blood pressure and osteoporosis, which causes bones to become less dense and weaken. Some of the other medications studied may have less serious, long-term side effects and effectively treat MS, these researchers wrote. Some of them, however, can also be extremely harmful, they wrote.

According to these researchers, those alternative medications and their side effects include the following:

  • Glatiramer acetate (Copaxone): Its potential side effects tend to occur soon after getting that injection and may include chest pain, fast heart beat, anxiety and shortness of breath. Glatiramer acetate seems to be safe during pregnancy.
  • Interferon-beta-1a (Avonex, Rebif): Immediately after that injection, patients may come down with mild flu-like symptoms, skin rashes, temporary problems with their thyroid or liver and a reduced number of the white blood cells that help fight off infection.
  • Natalizumab (Tysabri): Potential side effects of this injected medication include the John Cunningham virus, which an estimated three quarters of the US population carry. Most people never get sick from this virus. If the virus gets triggered in MS patients with weakened immune systems, however, it potentially may cause deadly encephalitis — a swelling of the brain.
  • Fingolimod (Gilenya): Patients taking this pill for the first time need to have their hearts monitored for six hours afterward to ensure their heart beat does not slow down too much. Also, these patients are at increased risk for skin cancer, liver dysfunction and reduced white blood cell count.
  • Dimethyl fumarate (Tecfidera) and teriflunomide (Aubagio), which the US Food and Drug Administration (FDA) approved for American patients in March 2013, potentially may cause gastrointestinal problems, liver dysfunction and decreases in white blood cells.

Interferon-B medications and glatiramer acetate do not become toxic to the body over time and can be used long term, the researchers wrote.

Natalizumab and fingolimod should be used only for patients who don’t respond well to interferon-B and glatiramer acetate, they wrote.

Given their severe side effects and lack of evidence that they do enough to lessen MS symptoms, mitoxantrone (Novantrone), azathioprine (Imuran) and cyclophosphamide (Cytoxan) should only be used as a last resort for patients who have not responded well to other treatments, the researchers wrote.

Dr. La Mantia and colleagues also wrote that evidence about the effectiveness of alemtuzumab (Campath, MabCampath, Lemtrada), a treatment for leukemia that also may help MS patients, is still under investigation. That medication has been approved for treatment in Europe, but the FDA last December blocked its approval for use in the United States.

These researchers concluded that steroids that were injected or taken as a pill were equally effective in treating MS symptoms, and that "could have a substantial impact on clinical practice by allowing outpatient instead of hospital management of [MS] relapses in many instances," they wrote.

"Recently, several new compounds have been developed and approved with the aim of favorably changing the disease course, but with varied success. The evaluation of the effectiveness of treatments for MS is complex, and identifying the most appropriate treatment for an individual patient may be difficult," Dr. La Mantia and team wrote.

What is less clear is how well any medications treat MS patients who no longer shift between having symptoms and having no signs of the disease. Those MS patients are simply getting steadily worse, the researchers wrote.

More research is needed on treatment options for that group of patients whose symptoms keep getting worse, these researchers concluded.

"A better understanding of the neuroprotective effects of the available drugs and newer compounds is needed. Evidence of effective treatments for ... [constantly worsening] MS is lacking," the researchers wrote. "Finally, evidence-based guidelines concerning which drugs to choose and when and how to change ... [drug treatment] during the course of the disease are needed to help physicians in the management of individual MS patients."

This study was published in April in CMAJ (Canadian Medical Association Journal).

These researchers had ready access to the prior studies and did not receive funding for their meta-analysis.

The researchers did not report any financial investments or other ethical conflicts that would shape study design, outcome or analysis.

Review Date: 
April 21, 2014
Last Updated:
April 22, 2014