Recovery from attacks
| Form | Medication & dose | Side effects |
| tablets | methylprednisolone 500mg daily for 5 days | insomnia, increased blood pressure, increased blood glucose levels, mood swings and fluid retention |
| intravenous infusion (drip) | methylprednisolone 1000mg daily for 3–5 days | insomnia, increased blood pressure, increased blood glucose levels, mood swings and fluid retention |
Slowing the progression of the disease
For primary-progressive MS
| Form | Medication & dose | Side effects |
| intravenous infusion (drip) |
Ocrelizumab (Ocrevus) 300 mg infusion followed 2 weeks later by a second 300 mg infusion |
the only FDA-approved disease-modifying therapy (DMT) those who receive this treatment are slightly less likely to progress than those who are untreated |
For relapsing-remitting MS
| Form |
Medication and dose |
Monitoring | Side effects | Additional info |
| injection |
Interferon beta medications: Interferon beta 1a: Avonex 30 micrograms (0.5 ml solution) (IM) once a week Rebif see spc Interferon beta 1b Betaferon is 250 microgram (8.0 million IU) contained in 1 ml of the reconstituted solution SC every other day Extavia is 250 microgram (8.0 million IU) contained in 1 ml of the reconstituted solution SC every other day |
LFT |
flu-like symptoms and injection-site reactions |
people taking interferons may develop neutralizing antibodies that can reduce drug effectiveness |
| injection |
Glatiramer acetate (Copaxone) 20 mg SC od at the present time, it is not known for how long the patient should be treated |
skin irritation at the injection site | blocks immune system's attack on myelin | |
| oral |
Fingolimod (Gilenya) 0.5 mg capsule once daily |
monitor BP and heart rate for six hours after the first dose | rare serious infections, headaches, high blood pressure and blurred vision | |
| Dimethyl fumarate (Tecfidera) 120 mg bd for 7/7 then maintenance dose of 240 mg bd | baseline MRI and FBC, LFT U&E baseline and every 3 months | flushing, diarrhea, nausea and lowered white blood cell count | monitor patient closely for features of progressive multifocal leukoencephalopathy (PML) (e.g. signs and symptoms of neurological dysfunction) and other opportunistic infections | |
| oral | Diroximel fumarate (Vumerity) bd | fewer side effects than dimethyl fumarate | similar to dimethyl fumarate but typically causes fewer side effects | |
| oral | Teriflunomide (Aubagio) 14 mg once daily | Baseline BP, LFT and during treatment | liver damage, hair loss | can cause birth defects when taken by both men and women; use contraception when taking this medication and for up to two years afterward. Couples who wish to become pregnant should talk to their doctor about ways to speed elimination of the drug from the body |
| Siponimod (Mayzent) 0.25 mg on days 1 and 2, followed by 0.5 mg on day 3, followed by 0.75 mg on day 4, followed by 1.25 mg on day 5, dose to be taken in the morning for the first 5 days; maintenance 2 mg od from day 6 onwards |
Baseline heart rate, BP, FBC, U&E, LFT & then during treatment eye examination recommended before initiation and 3–4 months after |
liver problems and low white blood cell count, changes in heart rate, headaches and vision problems | harmful to a developing fetus, so women who may become pregnant should use contraception when taking this medication and for 10 days after stopping the medication. Some might need to have the heart rate and blood pressure monitored for six hours after the first dose | |
| oral | Cladribine (Mavenclad) two treatment courses, spread over a two-week period, over the course of two years |
|
upper respiratory infections, headaches, tumors, serious infections and reduced levels of white blood cells | People who have active chronic infections or cancer should not take this drug, nor should women who are pregnant or breast-feeding. Men and women should use contraception when taking this medication and for the following six months. |
| infusion | Ocrelizumab (Ocrevus) |
|
irritation at the injection site, low blood pressure, a fever and nausea progressive multifocal leucoencephalopathy |
only DMT approved by the FDA to treat both the relapse-remitting and primary-progressive forms of MS Some people may not be able to take ocrelizumab, including those with a hepatitis B infection. Ocrelizumab may also increase the risk of infections and some types of cancer, particularly breast cancer |
| infusion | Natalizumab (Tysabri) 300 mg every 4 weeks, consider discontinuing treatment if no response after 6 months. |
annual MRI and LFT
|
Infusion reactions are common neurological symptoms, and for cognitive and psychiatric signs of Progressive Multifocal Leucoencephalopathy |
|
| infusion | Alemtuzumab IV consecutive days of drug infusions followed by another three days of infusions a year later | Infusion reactions are common |
This drug helps reduce relapses of MS by targeting a protein on the surface of immune cells and depleting white blood cells. This effect can limit potential nerve damage caused by the white blood cells. But it also increases the risk of infections and autoimmune disorders, including a high risk of thyroid autoimmune diseases and rare immune mediated kidney disease. The drug is only available from registered providers, and people treated with the drug must be registered in a special drug safety monitoring program. Alemtuzumab is usually recommended for those with aggressive MS or as second line treatment for patients who failed another MS medication. |
Managing MS symptoms
| Symptom | Medication & dose |
| muscle stiffness or spasms |
Muscle relaxants such as baclofen 5 mg tds gradually increased to 60 mg daily in divided doses review treatment if no benefit within 6 weeks of achieving maximum dose; maximum 100 mg per day. tizanidine 2 mg od then increase in steps of 2 mg daily in divided doses, increased at intervals of at least 3–4 days and adjust according to response; usual dose up to 24 mg daily in 3–4 divided doses; maximum 36 mg per day Onabotulinumtoxin A - see notes below |
| fatigue |
amantadine - 100 mg om for 1 week, increased to 100 mg bd; maximum 400 mg per day modafinil - off label methylphenidate - off label |
| mobility |
fampridine - 1 bd not prescribable on nhs dalfampridine - cheaper version after patent of fampridine expired currently only available in US people with a history of seizures or kidney dysfunction should not take this medication |
Onabotulinumtoxin A
- aka the botulinum toxin aka Botox used treat muscle spasms, spasticity, and bladder symptoms in patients with MS
- the therapy is based on the bacteria Clostridium botulinum — a toxin that blocks neuromuscular conduction between the nerves and the muscles
- the therapeutic result is a short-term localized relaxation of the targeted muscle
- injected into the muscles every three months to treat increased muscle stiffness in ankle and toe muscles in adults with lower limb spasticity, and in elbow, wrist, finger, and thumb muscles in adults with upper limb spasticity
- no studies yet that confirm Botox’s safety and effectiveness for treating upper limb muscles
Vitamin D
In 2015 scientists demonstrated a clear link between low vitamin D and MS. They found that people who naturally had lower levels of vitamin D (because of their genetics) were more likely to develop MS. Researchers in Oxford have also discovered that vitamin D could affect the way a gene linked to MS behaves. They showed that when vitamin D was present, the gene was more active. But there is currently no evidence that high vitamin D levels reduce the risk of developing MS.
If patient is Vitamin D deficient then recommend a supplement of 2000-5000 IU. Aim is to get the levels of vitamin D to around 40-60 nmol/l, whilst monitoring blood levels every 3 months
The risk of overdosing with vitamin D is rare, but can happen. With a very high level of vitamin D supplement, advised patient to follow a low calcium diet to prevent calcium building up in the body. Vitamin D toxicity and hypercalcaemia can cause kidney damage if left untreated.
