Treating Multiple Sclerosis (MS)
- Treatment for multiple sclerosis (MS) has grown substantially, giving doctors many more options to tailor care, with more than 25 DMT therapies now available, Dr. Nancy Sicotte, Chair of Neurology and Director of Multiple Sclerosis and Neuroimmunology at Cedars-Sinai, tells SurvivorNet.
- A key shift in MS treatment is the growing use of high-efficacy B-cell depleting therapies, often used early for better long-term outcomes.
- Treatment decisions are now highly individualized, based on disease risk factors, lifestyle preferences, and life plans like pregnancy.
- For patients with progressed disease, treatment is less about undoing damage and more about trying to delay further worsening and preserve function as long as possible, while researchers continue working on more effective options.
“There are more than 25 different [DMT] treatments available now for MS. They fall into a much smaller number of classes of medication, but I do think the big game changer was this class called B-cell depleters [B-cell depletion therapy, BCDT], and that includes Ocrevus (ocrelizumab), Kesimpta (ofatumumab) and all the different variations that we’re excited about— like Rituxan (rituximab),” Dr. Nancy Sicotte, Chair of Neurology, Director of Multiple Sclerosis and Neuroimmunology at Cedars-Sinai, tells SurvivorNet.
Read More“We do offer all of those options to people. We do tend to steer people toward the higher efficacy, if there are risk factors that we think may [give a patient] a higher risk of developing more severe disease.”
She noted that in patients with a higher number of spinal cord lesions, as well as in older individuals, men, and people of color, doctors tend to place greater emphasis on those specific treatment approaches when making care decisions.
Understanding Treatment For MS Progression
Dr. Sicotte explained, “In terms of progression, there’s really just ocrelizumab (Ocrevus) that showed a benefit in primary progressive MS. So, we do use that in people who have progressions, but in terms of how well that works in slowing progression, it’s a little disappointing. It doesn’t stop progression; it doesn’t reverse progression.
“There’s some evidence that it may slow it down a little bit. Sometimes that’s hard for the patient to detect that there’s been of a change. So this is definitely an area that we are looking for more effective therapeutics and have some things in the pipeline that we’re hopeful about.”
For women who are planning to become pregnant within the next year, Dr. Sicotte often prefers using Ocrevus (ocrelizumab) since it is given only once every six months and can better align with family planning timelines.
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“That gives a window for women to get pregnant before their next treatment. Pregnancy is sort of a protective time for MS, and we now know that we can put folks right back on their medications, even if they want to nurse, if they’re on one of the B-cell depleting agents, because it doesn’t appear in breast milk,” she added.
“So, sometimes that’s a determining factor. And you, as patients themselves, they say, ‘Oh, I don’t want to do it in an infusion,’ or, ‘I don’t want to give myself a shot.’
Dr. Sicotte then noted how some treatments require monthly self-injections, like Kesimpta (ofatumumab), which can be difficult for patients who are uncomfortable with needles.
For those patients, or for people who prefer not to inject themselves, there are also oral medication options available, allowing more flexibility in treatment choice.
“I would say that the key factor is, these medications work over time, so it has to be something that fits with the patient’s lifestyle and something that they will be willing to commit to and be able to take on a regular basis. That’s probably the most important factor in deciding,” Dr. Sicotte said.
More Treatment Options
Other types of treatment, explained by Dr. Sicotte, for progressive MS include:
- Tysabri (natalizumab): “A monthly injection, which can cause a rebound relapse if stopped abruptly, therefore not great for a young woman who might get pregnant,” Dr. Sicotte says. She says the drug has one very serious risk: a brain infection called Progressive multifocal leukoencephalopathy (PML) which is caused by the JC virus (human polyomavirus), but doctors test for exposure before prescribing. She notes that for eligible patients, Tysabri is generally well tolerated with a lower infection risk.
- Aubagio (teriflunomide): A daily oral medication. “This is absolutely contraindicated during pregnancy, so don’t offer it to young women,” explains Dr. Sicotte. It can also cause hair loss and raises infection risk, she adds.
- Mavenclad (cladribine): An oral medication given over a few weeks once a year. Dr. Sicotte says Mavenclad can only be used 2 years in a row. This drug comes with an increased risk for infections. However, it’s considered convenient because patients typically only need treatment once a year. “It’s now being used as de-escalation therapy frequently (for those patients coming off of b-cell depleters like ocrelizumab),” she adds.
- Kesimpta (ofatumumab): A monthly injectable B-cell therapy, which Dr. Sicotte says the data on this medication are “very good.” She explains, “Seems to be as effective as the first-generation B-cell depleters, suggesting a lower infection risk, but that is an impression rather than data-driven,” Dr. Sicotte says.
Understanding Multiple Sclerosis (MS)
Multiple sclerosis causes the immune system to attack cells that form the protective sheath that covers nerve fibers in the spinal cord. The disruption leads to communication problems between the brain and the rest of the body.
Once the protective barrier is damaged, the spinal cord struggles to communicate to the body’s arms, legs, and other parts to function normally.
Dr. Lauren Krupp, a neurologist at NYU Langone in New York City, describes MS to SurvivorNet as an “immune mediated condition,” which causes the immune system to work against itself.
“We’re not exactly sure why that happens, but it probably has to do with an exposure to a virus at some point in time. And in the effort to fight off that virus, the immune system turns against itself and specifically, a coating of the nerves called myelin,” Dr. Krupp explains. “The myelin that it affects involves the central nervous system, and that’s the brain and the spinal cord.”
Because it can involve different areas in the brain or spinal cord, Dr. Krupp explains, “the symptoms can vary in location.”
The National Institute of Neurological Disorders and Stroke describes MS as: “An unpredictable disease of the central nervous system, [MS] can range from relatively benign to somewhat disabling to devastating, as communication between the brain and other parts of the body is disrupted.”
Currently, there is no cure for MS (which researchers believe is an autoimmune disorder), though many people treat the disease using chemotherapy, medications, or steroid drugs.
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Contributing: SurvivorNet Staff
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