Multiple Sclerosis


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


Medication and dose

Monitoring Side effects Additional info 

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


flu-like symptoms and injection-site reactions

people taking interferons may develop neutralizing antibodies that can reduce drug effectiveness


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

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

  • This medication is designed to block the movement of potentially damaging immune cells from your bloodstream to your brain and spinal cord. It may be considered a first line treatment for some people with severe MS or as a second line treatment in others.

  • This medication increases the risk of a potentially serious viral infection of the brain called progressive multifocal leukoencephalopathy (PML) in people who are positive for antibodies to the causative agent of PML JC virus. People who don't have the antibodies have extremely low risk of PML.

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


amantadine - 100 mg om for 1 week,  increased to 100 mg bd; maximum 400 mg per day

modafinil - off label

methylphenidate - off label


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.

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