Multiple Sclerosis Treatment

Although no cure for multiple sclerosis (MS) exists yet, treatment can meaningfully improve quality of life if you are living with the condition, according to Luis Compres-Brugal, M.D., a Miami-based neurologist and director of the neuroimmunology/multiple sclerosis program at the Kenneth C. Griffin Neuroscience Institute, part of Baptist Health South Florida.

“With MS treatment, we aim to prevent new damage, slow or stop disability, and help patients live fulfilling lives despite ongoing symptoms,” he says. “We also evaluate subtle changes in function and track MRI scans to determine if new treatment options are needed.”

What exactly are those options? We spoke with top specialists about the latest thinking on multiple sclerosis treatment, what medications are available, how MS symptoms might be addressed, and which self-care strategies can best complement MS therapies.

Disease-Modifying Therapies for Multiple Sclerosis

Disease-modifying therapies (also called DMTs) are long-term medications that calm an immune attack, which reduces relapses and new lesions, explains Misbah Azeem, M.D., a neurologist who specializes in treating multiple sclerosis at National Jewish Health in Denver, CO. DMTs alter how the immune system works, thereby reducing inflammation and slowing MS progression.

“The tremendous research in this field has led to the development of more than 20 different FDA-approved disease-modifying therapies for MS, with around 11 different mechanisms of action,” he says. These medications are delivered through three primary routes:

• Infusions. Given at a hospital or infusion center, these DMTs vary in frequency depending on the medication and the health provider’s recommendation. They may be given every few weeks or a couple of times per year. Examples include ocrelizumab (Ocrevus), natalizumab (Tysabri), and ublituximab (Briumvi).
• Injectables. These are self-administered or given in a clinic, and may be taken weekly, every two weeks, or monthly, depending on the medication. Examples include interferons, glatiramer acetate (Copaxone), and ofatumumab (Kesimpta).
• Oral medications. These DMTs are pills or capsules that might be taken once daily or several times per day, depending on the formulation. Examples include dimethyl fumarate (Tecfidera), teriflunomide (Aubagio), and fingolimod (Gilenya).

Today, neurologists usually recommend starting a DMT as soon as possible after diagnosis rather than doing the conventional “step up” therapy that begins with symptom management and eventually progresses toward DMTs, says Dr. Azeem. That’s because these therapies have been shown to protect neurological function and reduce future damage, so the sooner you start one, the better your ability to control symptoms.

How Doctors Choose an MS Medication

With so many treatment options available, deciding on which one to use is complex. There are several factors that go into the process of choosing a medication for MS, says Dr. Azeem. That can include:

• Type of multiple sclerosis. Most treatments are designed for relapsing forms of MS, and fewer options are available for progressive MS. However, ocrelizumab is approved for treating primary progressive MS.
• Side effects. Some medications can increase the risk of infections or may require more monitoring of liver function.
• Disease activity. MRI results, recent relapses, and changes in physical function help guide treatment choices.
• Other conditions. Some medications may not be appropriate if you have other autoimmune issues, since treatment for one condition may trigger a flare-up in another.

“The goals and preferences of the person with MS is also a factor in deciding what medication to use,” Dr. Azeem adds. For example, some people may prefer pills they can take at home rather than going to an infusion center every few weeks.

Treatment for an MS Relapse

Unlike disease-modifying therapies that are designed to help lower inflammation and reduce MS-related damage in the long term, treatments for relapses are meant to be used for a brief time as a way to speed recovery, says Dr. Compres-Brugal.

“A relapse is often treated with a short course of high-dose steroids that can alleviate symptoms,” he notes. “The aim is to control the dysregulated immune response and speed recovery of the central nervous system.”

If steroids aren’t effective, other treatments may be considered, says Dr. Azeem. A typical second-line procedure is plasma exchange therapy, also called plasmapheresis, in which blood is taken from the body through an intravenous line and routed into a specialized machine that separates liquid plasma—which contains pro-inflammatory compounds—from red and white blood cells. The plasma is discarded and replaced with a special fluid that combines with the blood cells and is returned to the body. This has been shown to help people with MS cope with symptoms caused by proteins in their own plasma that are attacking their body.

Multiple Sclerosis Symptom Management

Disease-modifying therapies address the way multiple sclerosis affects the central nervous system and are aimed at slowing disease progression. But they’re not intended for managing specific symptoms, says Dr. Azeem. In MS, each symptom needs to be managed on its own, with treatment based on how much it’s affecting you.

Fatigue

One of the most challenging symptoms to treat is fatigue, says Dr. Azeem. There are currently no FDA-approved drugs specifically for MS-related fatigue, so treatment usually involves:

• Employing cooling strategies since heat worsens MS symptoms like fatigue.
• Getting regular exercise, which can not only significantly reduce fatigue but also improve muscle strength, balance, and coordination.
• Identifying secondary causes or contributors such as sleep disorders, mood issues, medication side effects, or other medical conditions like anemia, vitamin deficiencies, or thyroid dysfunction.
• Setting realistic expectations about how much activity can be done in a day and practicing energy conservation measures such as resting more often.

If fatigue is consistent and severe, medications such as amantadine and modafinil may be considered, says Dr. Azeem. These aren’t approved for MS specifically—amantadine is an antiviral used for Parkinson’s disease and modafinil was initially approved for narcolepsy—but they can be helpful for fatigue in some MS patients, he adds.

Muscle Stiffness, Spasticity, and Weakness

Regular stretching and physical activity form the cornerstones of treatment for muscle stiffness and spasticity, says Dr. Azeem. A physical therapist can help suggest exercises and create an at-home plan to maintain strength if you are experiencing MS muscle weakness.

According to the Multiple Sclerosis Association of America (MSAA), aquatic therapy can also be helpful since the natural buoyancy of the water enables people with MS to move with less effort. Also, the cooler temperature of a pool is useful for reducing fatigue and keeping body temperature managed, an important consideration since those with MS struggle with overheating.

The MSAA adds that medications may also be prescribed to treat spasticity. Examples include gabapentin (Neurontin), pregabalin (Lyrica), and baclofen (Lioresal).

Pain and Numbness

Pain related to MS is treated based on its severity, frequency, and potential cause, says Dr. Compres-Brugal. For example, medications like gabapentin or pregabalin may be used for nerve pain and numbness, while muscle relaxants might be considered for pain caused by muscle spasms.

Lifestyle changes can also be helpful for pain and numbness, he adds. These can include gentle stretching, massage, relaxation techniques, stress management, and better sleep habits.

Depression and Cognitive Changes

Depression, along with other mood disorders, is a common occurrence in MS. “Therapy, along with medication management, may be necessary,” Dr. Azeem says. “Symptoms such as nerve pain or migraine headache may influence which medication is used to address depression or cognitive issues.”

Vision Problems

Vision issues are common with MS and need to be evaluated by an ophthalmologist or a neuro-ophthalmologist to see if specialized lenses are required for visual correction or reduction of double vision, says Dr. Azeem.

When Are Mobility Aids Recommended for Multiple Sclerosis?

When walking, balance, coordination, and strength are affected, mobility aids for MS can be an important part of managing the condition. Devices such as canes, rollators, and wheelchairs provide support, improve stability, and reduce risk of falls.

Mobility aids can also help those with MS feel more confident and provide a way to better conserve energy, which is a crucial aspect of managing the disease, according to Lindsey Biel, OTR/L, an occupational therapist in private practice in New York City.

“Energy conservation with MS is key for feeling and functioning at your best,” she says. Using mobility aids can help someone with MS pace themselves even with multiple tasks to do during the day.

Occupational Therapy and Home Modifications for MS

Another important aspect of MS management, particularly with conserving energy in mind, is learning to navigate a home and other spaces, says Biel.

“Occupational therapists can assess your home or workplace and, with their specialized training in task analysis and task modifications, can help you to re-engineer the way you perform everyday activities to maximize your available energy,” she says. For example, an occupational therapist might:

• Help to reorganize a kitchen so that the dishware and cookware used most frequently are within easy reach. They may also recommend that you replace heavy ceramic dishes with lightweight melamine dishes.
• Help to perform activities like meal preparation, haircare, and putting on make-up while sitting rather than standing. They may recommend adaptive kitchen tools to make cutting and preparing food easier too.
• Help to set up a tub chair, handheld shower head, and a handy hook, and easy access to hair and body products for showering.

These may seem like simple tweaks, but they can give someone with MS a greater sense of control over their environment, which is an important way to support emotional health.

Lifestyle Strategies That Support MS Treatment

There are many lifestyle habits that can complement medical management of multiple sclerosis, says Dr. Compres-Brugal. “Regular exercise, good sleep, a healthy diet, not smoking, and managing blood pressure, cholesterol, and weight all support treatment,” he says. “Exercise in particular improves fatigue, strength, balance, and mood, and it can be adapted to almost any ability level.”

Having a strong relationship with your health provider and care team is another must-have to optimize multiple sclerosis treatment, adds Dr. Azeem. Regular check-ins and solid communication can go a long way toward helping with medication adjustment, meaningful lifestyle changes, and referrals to professionals like occupational therapists and psychologists.

Bottom Line on Treating Multiple Sclerosis

Perhaps more than any other immune-related chronic disease right now, treating MS is a story of both hope and frustration. Pinpointing the specific cause of the condition continues to elude scientists, making the development of a cure difficult. But at the same time, a growing body of research is spawning highly effective treatments for both the underlying disease and the vast range of symptoms it causes.

If you are living with multiple sclerosis and find your symptoms, mobility, or emotional health are getting worse, talk with your doctor about new treatment options that you may benefit from.