There is no cure for MS, but treatments can improve symptoms and reduce the number of relapses. Treatment options include medication, lifestyle changes and therapy modalities.
Medications that target your immune system can make relapses less frequent and less severe. These drugs are called disease modifying therapies and are taken as pills or injections.
Corticosteroids
Steroid medications can be very effective in short doses to help reduce the intensity of an MS flare. They can be taken orally or injected into the muscle. Steroids reduce inflammation by decreasing the activity of immune cells and decreasing the size of lesions that form on the brain and spinal cord. They also decrease swelling around the nerves and improve transmission of nerve signals. MRI studies have shown that steroids reduce the amount of fluid surrounding specific nerve areas, which allows for better nerve conduction within those areas.
The most common steroid used to treat an MS relapse is methylprednisolone. It is usually given in a IV or directly into the bloodstream, but high doses of oral methylprednisolone (MP) are also effective for many people during a relapse.
Despite the effectiveness of steroids, they are not considered to be an ideal treatment for an MS relapse. They do not significantly affect the long-term course of MS, and they have several side effects such as weight gain, fluid retention, bone loss, increased risk of infection and stomach ulcers, changes in mood, and other behavioral problems. They may even stunt a child’s growth or cause osteoporosis when used long-term.
For severe MS relapses that do not respond to high-dose corticosteroids, plasma exchange can be done at a hospital or specialized treatment center. Plasma exchange is a procedure that removes blood and returns it to the body, but it is expensive and requires hospitalization. If a person decides to continue taking steroids long-term, they must be careful and work with their doctor to taper off the medication gradually, so that withdrawal symptoms do not develop. This includes avoiding certain vaccines, such as live and attenuated influenza vaccines, during this time.
Stem Cell Therapy
Stem cells are special human cells that have the ability to develop into many different cell types, including muscle cells and brain cells. They can also help repair damaged tissues. Researchers believe stem cells may one day be used to treat serious illnesses such as paralysis and Alzheimer disease.
Scientists have developed several ways to grow stem cells in the lab. They can also be harvested from your own body – most often, from your bone marrow. These stem cells can then be injected into areas of your body where they’re needed to stimulate the production of new tissue or to replace existing tissue. For example, if you have osteoarthritis of the knee, stem cells can help heal the cartilage in the joint.
These treatments are called disease-modifying therapies because they modify the way your immune system works. They can reduce the number of relapses and slow the progression of disability in people with relapsing MS and some forms of secondary progressive or progressive relapsing MS. They can also decrease the amount of damage to nerve fibers in your central nervous system.
Some examples of disease-modifying therapies include cladribine (Mavenclad) and alemtuzumab (Lemtrada, Campath). They both work by suppressing certain immune cells that may cause problems in people with MS. They may also affect the growth of tumors. They can have side effects like thyroid problems and low platelet counts.
Another treatment that involves transplanting your own stem cells is under study for its potential to reduce inflammation and “reset” your immune system in people with multiple sclerosis. This therapy is called autologous hematopoietic stem cell transplant or aHSCT. It is under investigation because it’s very risky and can have serious side effects, including infections.
Mitoxantrone
Mitoxantrone (Alkeran) is a chemotherapy drug that has been approved for use as an MS disease-modifying treatment. It works by destroying white blood cells that attack the protective sheath that surrounds nerve fibers in your brain and spinal cord. It also interferes with the production of inflammatory molecules that cause damage to nerves. You can take it by injection every 3 months for 2 to 4 years. It reduces the number of relapses, MRI lesions and disability progression in people with relapsing-remitting MS. It is also known to decrease the risk of opportunistic infections, such as pneumonia and bladder cancer. However, it is associated with a higher risk of leukemia, especially acute promyelocytic leukemia.
Your doctor will check for any preexisting conditions before you start taking this medication. They will also ask you about other medications you’re taking, including vitamins and supplements. You should avoid getting pregnant or breastfeeding while taking it. It may harm the fetus. You should use effective birth control methods while taking it and for 6 months after you stop.
Rituximab (Rituxan) is another infusion treatment for MS. It is FDA-approved to treat relapsing and primary progressive MS, and it’s the first drug approved to slow down the worsening of PPMS by blocking certain immune cells from attacking your nerves. It is used as an off-label treatment for MS in people with severe relapses who aren’t helped by other treatments, including rituximab, ocrelizumab and alemtuzumab.
This medication can affect your heart and nervous system, so it’s important to tell your doctor if you have any heart or respiratory problems before you start taking it. It can also make your urine a blue-green color. Your doctor will watch you closely for any serious reactions, such as chest pain, lung complications or high blood pressure.
Ocrelizumab
Ocrelizumab is an anti-CD20 monoclonal antibody approved by the FDA in March 2017 to treat relapsing remitting MS (RMS). It decreases relapse rate and disability progression in relapse-prone RMS and primary progressive MS. It is also being investigated in people with secondary progressive MS. In a phase III trial, ocrelizumab significantly decreased annual relapse rates and improved disability progression measured by the Expanded Disability Status Scale (EDSS) score in both treatment-naive RMS patients and those previously treated with interferon a-4 or natalizumab (Lemtrada).
Ocrelizumab reduces the number of B cells that carry out harmful attacks on the myelin covering around nerves in the brain and spinal cord. It does so by blocking the enzyme phosphatase alkaline phosphatase that B cells need to function. It was the first DMT to be approved for PPMS and is being studied in secondary progressive MS.
Infections, such as upper respiratory tract infection and nasopharyngitis, are common in people receiving ocrelizumab. However, serious infections are very rare.
Although it is expensive, ocrelizumab is covered by most insurance companies and patient assistance programs are available. It is infused into the body via intravenous infusion. The initial dose is two infusions given 14 days apart and then a single dose is administered every 6 months.
Another disease modifying therapy is alemtuzumab, which decreases the amount of abnormal immune cells in the blood and in the cerebrospinal fluid that attack the central nervous system. However, it is not effective in secondary progressive MS. Other experimental therapies include Bruton’s tyrosine kinase inhibitors, which may help decrease the inflammation in MS. This therapy involves destroying the immune system and replacing it with transplanted healthy stem cells.
Autologous Hematopoietic Stem Cell Transplant (aHSCT)
Autologous hematopoietic stem cell transplant (aHSCT) is a treatment that uses a person’s own blood or bone marrow to ‘re-boot’ their immune system, to stop it attacking the brain and spinal cord. This is a more intensive therapy than DMTs and involves high dose chemotherapy. It also has much higher short term risks than other MS treatments. In a clinical trial, aHSCT reduced relapses and disability progression compared with DMTs. This is an option for people with highly active relapsing remitting MS who do not respond to DMTs. At Sheffield Teaching Hospitals NHS Foundation Trust we are able to offer this treatment for people with SPMS who have had recent relapses and new or enlarging MRI lesions. It is not available for primary progressive or secondary progressive MS.
This treatment is only offered at specialist centres where the patient will be cared for by haematology experts. It is important to discuss this option with your neurologist before referral. The risk of mortality in this treatment is 1%.
AHSCT might reduce relapses and slow down progression for some people with progressive MS who have inflammation (shown on MRI scan or by relapses). It may not be as effective in other people with progressive MS, where there is no active inflammation. HSCT can also cause long-term side effects such as a lowered fertility and early menopause, as well as cancer or other illnesses caused by the chemotherapy drugs used in the procedure. It is therefore only offered to people who are very fit and whose doctors feel it is the best option for them. This treatment is very expensive and it may be difficult to get funding.
