Disease modifying therapies (DMTs)
Treating MS with DMTs
DMTs – a closer look
Choosing a DMT
Side effects
What if I choose not to take a DMT?
Disease modifying therapies (DMTs) are medications that change the course of MS. They are designed to reduce the number of relapses and slow condition progression. In this booklet we will delve deeper into what they are, how they work and their impact on the management of MS.
There are many forms of DMT available, each of which affect the number and severity of relapses to varying degrees. According to the National Institute for Care Excellence’s (NICE) clinical guidelines for MS, a relapse can be diagnosed by a GP or neurologist if, ‘The person with MS has developed new symptoms or has a worsening of existing symptoms, and these symptoms have lasted for more than 24 hours in the absence of infection or any other cause, after a stable period of at least one month.’ (1).
Additionally, some of these drugs have been found to delay the long-term progression of MS and reduce the number of new lesions forming.
Not everyone with MS will benefit from DMTs in the same way and people will respond differently to treatment. Equally, it is important to note that not all side effects will be experienced and sometimes it can take a while to find the right drug for you.
A treatment algorithm was first published in 2018 by NHS England which sets out the eligibility criteria for the prescribing of these drugs. It can be used by MS specialists and their patients as an aid to decision making and underpin equality in terms of accessing different DMTs (2).
The supporting reference document for the algorithm sets out some important criteria which should be accounted for when making DMT decisions. For example, it states that treatment should be recommended as soon as a patient becomes eligible. This eligibility should consider important factors such as disability, given that patients only qualify for a DMT if they are showing sustained disability to a level of less than 7.0 on the Expanded Disability Status Scale (EDSS). For females, pregnancy planning should also be considered so that a suitable DMT can be prescribed (2). While this treatment algorithm was produced for use within NHS England, MS health professionals in other UK nations will follow similar frames of reference.
People with MS should be supported by a specialist neurologist, one who has experience of managing patients with this condition. They should assess your eligibility and suitability for DMTs and should explain the options available to you, if any. You may also be offered a choice of DMTs to take. Once treatment has started, patients should remain under the supervision of MS specialist neurologists and nurses.
For relapsing remitting MS (RRMS) the current list of licensed DMTs is divided broadly into three classes
It is important to note that if treatment is found to be ineffective, or intolerable side effects are experienced, it should be stopped under the support and guidance of your neurologist and an alternative offered if possible.
Other reasons for stopping treatment are if secondary progressive MS (SPMS) is confirmed along with the absence of relapse activity. It is also important to be aware that autologous hematopoietic stem cell transplantation (AHSCT/HSCT) is considered to be a DMT and is available as a second or third-line treatment option (2). AHSCT/HSCT is usually reserved for those with highly active RRMS who have tried the highly effective medication-based DMTs without success. We have produced a booklet dedicated to this treatment which provides more detail on this complex medical process.
Pregnancy can also lead to a drug being stopped as many are not suitable to continue use. However, some DMTs may be considered safe or can be used instead of other drugs for an interim period until the original drug can be resumed safely.
For people affected by SPMS and primary progressive MS (PPMS) where there is still inflammatory activity evidenced via MRI scans, the following DMTs may also be available.
Again, additional qualifying criteria apply to underpin individual eligibility for each of these treatments (2).
More information Our HSCT and MS Choices information booklet provides more details about this treatment.
Patients with RRMS who have had two or more clinical relapses in the previous two years are considered to have ‘active’ disease which means they are eligible for treatment with a DMT. People who have not had any clinical relapses yet show new MRI lesions are also considered for treatment.
All people with active RRMS should be considered for treatment as early as possible. Those with higher levels of disease activity may prefer to start with the more effective drugs (2).
If a patient is experiencing frequent clinical relapses and/or further MRI activity when either untreated or on a moderately effective drug, they are considered to have more active MS (2).
To meet the criteria for high disease activity, a person must show unchanged, increased or more severe ongoing relapses, compared to the previous 12 months, despite taking beta interferon or glatiramer acetate.
Also called highly active or severe RRMS, rapidly evolving severe RRMS (RES-RRMS) is defined as having two or more disabling relapses in one year, as well as new MS activity in the brain showing up as lesions on an MRI (2).
For patients with more active MS, a highly effective DMT is recommended.
Currently, there are no DMTs recommended to treat non-relapsing, or non-active SPMS. However, some people who experience relapsing SPMS, or ‘active’ SPMS, whereby relapses are present or there is disease activity shown on MRI scans, may be eligible for one.
Mayzent is approved to treat ‘active’ SPMS, evidenced by at least one relapse in the previous two years and/or inflammatory activity is shown via MRI, and/or progression is identified independent of relapses (3) (4).
Ocrevus is available to treat early-stage, inflammatory PPMS (5) (6). It is the first drug to show evidence in clinical trials of slowing down and reducing disability progression in PPMS.
Although not technically a classification of MS, CIS is used to describe a first neurological episode that lasts at least 24 hours and is caused by inflammation/demyelination in one or more areas of the central nervous system. CIS is sometimes diagnosed by neurologists before a formal diagnosis of MS can be made. If a neurologist believes that a patient with CIS has a high risk of developing MS, they may suggest taking a DMT, as it may prevent or at least delay the occurrence of a further neurological episode.
The NHS England treatment algorithm states that children should be treated using the same guidelines as adults. Children may receive DMTs if they are licensed for children, or if there is a recommended dose for children.
Ideally, children with MS who are aged under 16 should be treated in a specialist clinic with a combined team preferably including adult and paediatric neurologists with a particular interest in MS (2).
For further information on starting DMT treatment, changing to a DMT that you feel could be more suitable or indeed stopping treatment altogether, please speak to your MS nurse or neurologist. It is important to be aware that DMTs should be accessible to people of all ages, with eligibility based on clinical need alone.
More information Our Types of MS Choices information booklet provides further reading on the different variants of MS.
Earlier in this booklet we listed the different DMTs that are currently available for some people with MS in the UK. Below we take a closer look at these, but first we will attempt to clarify two issues which have become more prominent over the past few years. These being the availability of generic and biosimilar versions of DMTs.
To explain this, we need to understand that when a pharmaceutical company develops a drug, they can request that it is patented, which is a legal protection that prevents any other company from making and selling it. This patent is not finite and therefore will eventually expire and cannot be renewed. This then leaves the door ajar for other companies to create and sell copies or similar versions of the drug, known as ‘generic’ and ‘biosimilar’ medicines respectively.
These are an identical copy of the drug which was originally developed, this includes its active ingredients, how efficacious it is and its safety.
An example of generic DMTs can be found with fingolimod in the UK. This was originally developed and marketed with the brand name Gilenya by Novartis Pharmaceuticals UK Ltd. Now the UK patent has expired, there a number of generic versions of fingolimod available provided by a range of pharmaceutical companies (7).
Medicines that are biosimilar are those whose make-up is very close to the original, including the same active ingredients, biological activity, efficacy and safety, but with some slight differences – hence they cannot be classed as a generic medicine. There must be strong evidence that shows biosimilar medicines hold no clinically meaningful difference to the original version.
A recent example can be found with natalizumab in the UK. Originally developed and marketed by Biogen under the brand name Tysabri, a biosimilar version is now available with the brand name Tyruko, developed and distributed by Sandoz Ltd. A recent randomised clinical trial which compared this biosimilar form of natalizumab to Tysabri found no difference between both in terms of efficacy, safety, and immunogenicity for patients with RRMS (8).
In the UK, as with all medicines, the safety of generic and biosimilar DMTs must be approved by the Medicines and Healthcare products Regulatory Agency (MHRA) prior to being made available.
The following DMTs are currently available to treat MS in the UK
Aubagio (teriflunomide)
Avonex (beta interferon 1a)
Brabio (glatiramer acetate)
Briumvi (ublituximab)
Copaxone (glatiramer acetate)
Gilenya (fingolimod)
Kesimpta (ofatumumab)
Lemtrada (alemtuzumab)
Mavenclad (cladribine)
Mayzent (siponimod)
Ocrevus (ocrelizumab)
Plegridy (beta interferon 1a)
Ponvory (ponesimod)
Rebif (beta interferon 1a)
Tecfidera (dimethyl fumarate)
Tysabri/Tyruko (natalizumab)
Vumerity (diroximel fumarate)
Zeposia (ozanimod) (Scotland only)
Aubagio inhibits the function of specific immune cells that have been implicated in MS. It targets the production of a key mitochondrial enzyme required by white blood cells, which in turn reduces the activated T and B immune cells associated with MS. Additionally, it has been shown to have other anti-inflammatory and immune-modulating properties (9) (10).
Studies showed that Aubagio reduced relapses by one-third. They also evidenced that a higher dose reduced the risk of disability progression by just over 30 per cent (9) (10).
Interestingly, studies have also shown that teriflunomide can reduce the levels of the antibody IgG in the system. Elevated levels of this antibody are connected to the Epstein-Barr virus (EBV) which is linked to MS onset and progression (11).
Aubagio is taken as a tablet, once a day.
Sanofi
Yes. Teriflunomide forms available from AAH Pharmaceuticals, Accord, Alliance Healthcare, Dr Reddy’s, Perennial Pharma, Teva and Viatris (12).
Aubagio is licensed for relapsing remitting MS (2).
Common side effects are gastrointestinal upset, hair thinning and changes in liver function. Aubagio should not be taken by women considering pregnancy because of potential risks to the unborn baby. A woman of child-bearing age considering Aubagio must take a pregnancy test and ensure adequate contraception is in place before starting the drug. The drug stays in the body for a long time and if a woman taking Aubagio suspects pregnancy, she must immediately contact her GP and, if a pregnancy is confirmed, it can be flushed out of the body by taking activated charcoal or cholestyramine over several days (9) (10).
Interferons are proteins produced naturally by the body that help us fight infection. Avonex blocks the action of one type of protein called gamma interferon. It reduces the autoimmune reaction that causes inflammation and destruction of myelin (13) (14).
It has been shown to reduce the rate of relapse by about one-third in people with RRMS. It also reduces the severity of relapses that occur (13) (14).
Avonex must be injected into the muscle once a week and should be stored in the fridge.
Biogen
No
Avonex is used to treat RRMS (2).
What are the side effects? The most common side effect experienced when taking Avonex is flu-like symptoms after injecting.
Injection-site irritations may also occur, such as redness, swelling, and itching.
Other less common side effects from Avonex can be mood swings, fever and blood abnormalities. Most people find these effects reduce over a three-month period of taking the drug. If they persist, a conversation with an MS nurse or neurologist would be recommended (13) (14).
Brabio works differently from interferons in that it is a synthetic combination of four amino acids that resemble the myelin protein. It is thought to work by preventing the production of immune cells that attack myelin (13) (15) (16).
The rate of relapse in people taking Brabio is generally reduced by one-third (13) (1) (16).
It needs to be injected subcutaneously, which is under the skin. There are two doses, 20mg and 40mg. One is taken as a daily injection, and the other is taken three times a week. It needs to be stored in the fridge.
Viatris
Brabio is a generic version of Copaxone.
Brabio is licensed for RRMS and some people with CIS (2).
Common side effects are injection-site reactions, indentations under the skin known as lipoatrophy, chest tightness, headache, anxiety and nausea. Less common side effects include thyroid changes, blood cell changes, and palpitations (13) (15) (16).
In MS, the immune system mistakenly attacks the protective covering of nerve cells, and B cells are a key player in thisattack. Briumvi is a monoclonal antibody that works by targeting and eliminating these B cells, which helps to lower the risk of relapses, eases symptoms, and slows condition progression (17).
Studies have found that relapse rates in people with RRMS were reduced by over 50 per cent in those taking ublituximab when compared with participants taking teriflunomide (17).
Briumvi is administered by infusion every six months. The initial infusion usually takes around four hours to complete, with a second dose administered two weeks later. This will take approximately one hour. Subsequent doses are applied by infusion every six months thereafter, each taking approximately one hour to complete (17).
Neuraxpharm
Briumvi is recommended for people with active forms of RRMS (18).
Infusion reactions are the most frequently reported side effects, such as itching, rash and difficulty breathing. These are generally short-lived. At the start of each infusion, a corticosteroid and an antihistamine are given to the patient to help prevent any reactions (17). The most common potential side effects include the risk of contracting respiratory tract infections, coughs and colds and herpes virus infections, for example cold sores or shingles (17).
Copaxone works differently from interferons in that it is a synthetic combination of four amino acids that resemble the myelin protein. It is thought to work by preventing the production of immune cells that attack myelin (13) (19) (20).
The rate of relapse in people taking Copaxone is generally reduced by one-third (13) (19) (20).
It is injected subcutaneously. There are two doses, 20mg and 40mg. One is taken as a daily injection, and the other is administered three times per week. It needs to be stored in the fridge.
Teva
Yes. Brabio is a generic version of Copaxone (21)
Copaxone is licensed for RRMS and some people with CIS (2).
Common side effects are injection-site reactions and lipoatrophy (indentations under the skin), chest tightness, headache, anxiety, nausea. Less common side effects include thyroid changes, blood cell changes and palpitations. (13) (19) (20).
Gilenya is an immune-modulating drug, which attaches to the surface of certain white blood cells, known as lymphocytes, causing a number of them to be retained within the body’s immune system. As a result, fewer lymphocytes get into the bloodstream and fewer reach the central nervous system meaning the potential for an immune attack on the cells of the brain and spinal cord is reduced (22) (23).
Gilenya was shown to reduce the risk of relapses by 67 per cent compared to a placebo in trials (24).
It is taken in the form of a capsule, orally, once a day.
Novartis
Yes. Fingolimod forms available from AAH Pharmaceuticals, Accord, Amarox, Dr Reddy’s, Glenmark Pharmaceuticals, Sandoz, Sun Pharma, Teva, Tillomed, Viatris and Zentiva Pharma (25).
Gilenya is a ‘more effective’ drug treatment which is licensed for adults with highly active relapsing remitting MS. This is characterised as experiencing one relapse in the previous year despite being on another disease modifying therapy, such as an interferon, for at least 12 months (2).
Possible side effects include changes to liver function, macular oedema which is an accumulation of fluid in the macular area of the eye that sometimes causes blurred vision, headache, respiratory tract infection, shortness of breath, diarrhoea and nausea. Gilenya can also cause a decrease in heart rate, so your first dose will be monitored in hospital for six hours (22) (23) (24).
Kesimpta is a monoclonal antibody, similar to that of Ocrevus (ocrelizumab). It targets and attaches to specific markers in the immune system called CD20. These form on the surface of a type of white blood cell called B cells. It is thought that these B cells attack the myelin that surrounds nerve cells and causes inflammation. Kesimpta targets these B cells and removes them, reducing their overall activity (26) (27).
Compared to Aubagio (teriflunomide), Kesimpta reduces the risk of relapse by 50 to 59 per cent. Trials showed that people taking this drug had fewer, smaller, or no new areas of active lesions on an MRI scan. It also helps to relieve symptoms and slow down the progression of the condition (26) (27). It is suggested Kesimpta is as effective as Lemtrada, Tysabri and Ocrevus (28).
Kesimpta is self-injected, subcutaneously. It is injected weekly for the first three weeks, then you skip a week, before continuing with monthly injections. It needs to be stored in the fridge and taken out 15 to 30 minutes before injecting to allow it to reach room temperature (27).
Kesimpta is approved for use in adults with active RRMS. It is classed as a highly effective treatment. It can be offered as a first-line drug therapy (2).
The most common side effects reported for Kesimpta include upper respiratory tract infections, urinary tract infections, injection-related reactions such as fever, headache, muscle pains, and tiredness. Injection-site reactions are also common, such as redness, itching and swelling. These reactions mostly clear up the same day. Other common side effects include oral herpes, and a reduction in the blood level of immunoglobulins which help to protect against infection (27).
Lemtrada was originally licensed for the treatment of leukaemia. It is a monoclonal antibody which kills T-cells, a type of lymphocyte involved in the MS immune response. Once the T-cells are killed, the immune system repopulates, leading to a modified immune response that no longer regards myelin and nerves as foreign, and therefore stops attacking them (29) (30).
In two studies, Lemtrada was shown to be effective in reducing the number of relapses in people with RRMS. One clinical trial compared Lemtrada to Rebif in people who had not previously been treated with a DMT. Relapses were reduced by 55 per cent compared to Rebif (31).
In the second trial the drug was again compared to Rebif. In people who had experienced at least one relapse whilst on therapy, Lemtrada reduced the number of relapses by 49 per cent compared to Rebif (32).
Lemtrada is delivered by two infusions, 12 months apart. The first infusion is delivered over five days, and the second over three days. Infusions take place in a hospital or infusion clinic.
Lemtrada is highly effective when treating more active forms of RRMS (2).
Side effects reported for Lemtrada include one-third of people reporting changes to their thyroid function, which while treatable, can mean lifelong medication is necessary. One per cent of people reported a blood clotting disorder called immune thrombocytopenic purpura (ITP). While serious, ITP can be treated effectively. Other adverse effects reported relate to kidney function, reactions at the infusion site and respiratory infections.
More common reported side effects were flu-like symptoms after the infusion was given, and some may experience an itchy rash which can be managed by antihistamines (29) (30).
Mavenclad is an immune-modulating drug that targets specific lymphocytes, T-cells and B cells. The drug interferes with DNA synthesis and repair, therefore reducing the number of these lymphocytes. It is these cells that are thought to be involved in the immune response which attacks myelin, causing demyelination (33) (34).
Studies have shown that Mavenclad reduces relapse rate significantly and delays disability progression by reducing the loss of brain cells, sustained for six months compared with a placebo (35).
Mavenclad is taken as a tablet via two courses, one year apart. The first course is taken over five consecutive days in the first month and over five consecutive days in the second month. The second course is given 12 months later in the same way as the first course. The number of tablets taken in each course is dependent on the individual’s weight.
Merck-Serono
Mavenclad was initially approved to treat highly active RRMS. Its use has since been extended to treat less active RRMS.
One of the most common side effects of taking Mavenclad is lymphopenia, which means a reduction in white blood cells. This can increase the risk of getting infections. Other common side effects include shingles, cold sore, rash, and hair loss. If a patient has shingles, then Mavenclad may need to be stopped until the infection is treated and cleared (34).
Mayzent is an immune-modulating drug which works by reducing the amount of circulating white blood cells, known as lymphocytes, preventing them from being able to move freely within the body. Fewer cells are then able to reach the brain and spinal cord, therefore reducing nerve damage caused by SPMS (36).
Studies have shown that Mayzent helped to slow disability progression by 37 per cent, in those with active SPMS, compared to placebo. In slowing the progression, it also delayed the time to wheelchair dependency in a subgroup of patients, with an EDSS score of 6.5, who were high risk of reaching wheelchair dependency, compared to placebo (37).
It is to be taken by tablet, once a day. Tests will be required before starting treatment to determine the correct dosage. This will depend on how well the tablet is broken down in the body (36). Dosage is increased gradually over the first five days of treatment. This is to reduce the impact on the heart in case of irregular or slowed heartbeat.
Mayzent is approved for treating SPMS when there is evidence of disease activity. This could be in the form of relapses or inflammatory activity on MRI (3).
Most commonly associated side effects include slow heart rate, headache, high blood pressure, infections due to lowered white cell count and visual disturbances (36).
Ocrevus is a monoclonal antibody that has been designed to target and attach to a specific marker in the immune system called CD20 on the surface of certain types of white blood cells known as B cells. These B cells are what attack the immune system and cause inflammation and damage. Ocrevus targets these cells to help reduce their activity (38).
Studies have shown that Ocrevus can reduce annual relapse by 50 per cent compared to Rebif. There is also evidence that the drug reduced disability progression and the number of lesions shown on an MRI when compared with beta interferon. Loss of brain cells was also reduced, and no evidence of disease activity (NEDA) was seen in patients taking Ocrevus, again when compared to Rebif (39).
Ocrevus is administered by infusion or injection. The initial infusion is given in two separate doses, two weeks apart. After that it is one single dose administered every six months. Each infusion takes around three to four hours to complete (38). The injectable form is subcutaneous and is only administered by a doctor or nurse every six months. It takes around 10 minutes for the injection process to complete and you will be monitored for around 60 minutes after the initial injection has taken place. This is to ensure that any reactions to the injection are managed appropriately (40).
Roche
Ocrevus is highly effective when treating more active forms of RRMS. It is usually only available if Lemtrada (alemtuzumab) is contraindicated or unsuitable (40). It is also available for those with early stage inflammatory PPMS (5).
Infusion and injection reactions are the most frequently reported side effects, such as itching, rash and difficulty breathing. These are generally short-lived. Before each treatment, a corticosteroid and an antihistamine are given to the patient to help prevent any reactions (41) (42).
Infections are also common, such as chest infections, coughs and colds and herpes virus infections, for example cold sores or shingles (41) (42).
Interferons are proteins, produced naturally by the body that help us fight infection. Plegridy blocks the action of one type of protein called gamma interferon. It reduces the autoimmune reaction that causes inflammation and destruction of myelin (43).
It has been shown to reduce the rate of relapse by about one-third in people with RRMS. It has also shown to reduce the severity of relapses that occur (43).
Plegridy is self-injected under the skin every two weeks and should be stored in the fridge. You may be advised to start treatment on a low dose and gradually increase it, to avoid any potential side effects (44).
Plegridy is used to treat RRMS (2).
The most common side effect experienced when taking Plegridy is flu-like symptoms after injecting. Injection-site irritations may also occur, such as redness, swelling, and itching. Other less common side effects can be mood swings, fever and blood abnormalities.
Most people find these effects reduce over a three-month period of taking the drug. If they persist, a conversation with an MS nurse or neurologist is recommended (43) (44).
Ponvory is an immune-modulating drug. It reduces the amount of circulating white blood cells, known as lymphocytes and keeps them in the lymph nodes. Fewer cells are then available to attack the myelin sheath. This leads to a reduction in nerve damage and relapses (45).
A randomised clinical trial showed that people taking ponesimod have fewer relapses than those taking teriflunomide. A significant improvement in fatigue was also seen in comparison (46). It has also been evidenced that higher dose ponesimod led to a 52 per cent reduction in annualised relapse rate, compared to placebo (47).
It is taken as a tablet, once per day. Dosages are started low and gradually increased over the first 14 days (45).
Janssen-Cilag
Ponvory is used as a first-line treatment for people with active RRMS as defined by MRI. It can also be used as a second line treatment (48).
The most common side effects include the common cold, raised liver enzymes and upper respiratory tract infection. Other less common side effects include dizziness, headache, vertigo, macular oedema, and anxiety. Ponvory can also cause an initial decrease in heart rate. An electrocardiogram (ECG) will be given to check the electrical activity of the heart before the first dose. If there is an increased risk of a slowed heart rate you will be monitored for up to four hours after your first dose. An ECG will also be repeated at the end of this initial monitoring (45).
Interferons are proteins, produced naturally by the body that help us fight infection. Rebif blocks the action of one type of protein called gamma interferon. It reduces the autoimmune reaction that causes inflammation and destruction of myelin (13) (49).
Rebif has been shown to reduce the rate of relapse by about one-third in people with RRMS. It also reduces the severity of relapses that occur (13) (49).
Rebif must be injected under the skin three times per week and should be stored in the fridge. It comes in two dosages – 22mcg and 44mcg (49).
Rebif is used to treat RRMS (2).
The most common side effect experienced when taking Rebif are flu-like symptoms after injecting. Injection-site irritations may also occur, such as redness, swelling, and itching. Other less common side effects can be weakness and tiredness, fever and blood abnormalities. Most people find these effects reduce over a three-month period of taking the drug. If they persist, a conversation with an MS nurse or neurologist would be recommended (13) (49).
It is thought that Tecfidera promotes an anti-inflammatory effect when the immune system attacks myelin, therefore reducing any damage that may be caused to the central nervous system (50) (51).
Studies have shown that Tecfidera reduces the annual MS relapse rate by around one-half. During trials, MRI scans showed fewer, smaller or no new active lesions. Some studies also showed a significant reduction in the progression of the condition (50) (51).
Tecfidera is taken as a tablet, twice a day. Initial dosage is low and gradually increased over a two-week period.
Yes. Dimethyl fumarate forms available from Almirall, Celix Pharma, Genus Pharmaceuticals, Teva, Viatris, Wockhardt and Zentiva (52).
Tecfidera is used as a first-line treatment for people with active RRMS, defined as two clinically significant relapses experienced over the previous two years (2) (52).
Common side effects reported are flushing and feeling hot, headaches, gastrointestinal upset and decreased white blood cell count (50) (51).
A monoclonal antibody that works in a different way to injectable therapies, Tysabri binds to specific adhesion molecules within the immune cells. This stops the cells from crossing the blood brain barrier and entering the central nervous system, thereby reducing inflammation and nerve damage (53) (54). Tyruko is a biosimilar version of Tysabri which is now available. See the section titled ‘Biosimilar medicines’ for more information.
In studies, people with rapidly evolving severe RRMS showed a decrease of 81 per cent in relapses when taking natalizumab. People with RRMS showed a reduction of around two-thirds in the number of relapses, fewer MS lesions detected during MRI scans and a significantly reduced rate of condition progression (53) (54) (55).
Tysabri is administered by intravenous infusion every four weeks at either an infusion centre or a hospital. It has been evidenced that Tysabri is as effective when administered every six weeks, lowering the risk of potential side effects (56). In 2021, Tysabri was authorised for use in injection form. This is to be given as a monthly subcutaneous injection by a healthcare professional. Studies show that subcutaneous Tysabri is as effective and safe as the intravenous infusion version (57).
Tysabri is highly effective when treating more active forms of RRMS (2).
Side effects can include dizziness, nausea, joint pain, shivering and sometimes inflammation of the nose and throat. People taking natalizumab are at an increased risk of developing a serious condition called progressive multifocal leukoencephalopathy (PML), which is a rare but sometimes fatal brain infection that affects the central nervous system. PML is caused by a virus called the John Cunningham virus (JCV). Each potential natalizumab patient is tested to check whether they are positive for JCV as this can help to establish their risk of developing PML.
Risk factors associated with PML are the presence of anti-JCV antibodies and the length of time on treatment. There is a slightly increased risk for patients who remain on the therapy for more than two years. As the JCV is airborne, patients can develop it at any time. This means that those who test negative for JCV should be retested at regular intervals.
Patients who have been on immune suppressants prior to treatment also have an increased PML risk factor. Despite the risks, the benefits of natalizumab continue to outweigh the risks for many people with highly active RRMS (53) (54).
Vumerity is thought to have an anti-inflammatory effect when the immune system attacks myelin, therefore reducing any damage that may be caused to the central nervous system (58).
Studies show that Vumerity significantly reduces the amount of active MS lesions on MRI scans. It has also been found to reduce relapse rates on a similar level to Tecfidera (59).
It is taken as a tablet, twice a day. A low dose is taken for an initial seven days at which point a higher maintenance dose is required (58).
Vumerity is prescribed for people with RRMS who have moderately active disease in the form of a recent relapse, or new lesions (60).
Studies show Vumerity is well tolerated when compared to Tecfidera, with gastrointestinal upset being mild to moderate. It is still one of the more common side effects, but with a lesser impact on daily life (60). Other common side effects include flushing, nausea and an increased risk of acquiring infections (58).
Zeposia belongs to a group of drugs which work by reducing the amount of circulating white blood cells, known as lymphocytes, and preventing them from being able to move freely within the body. This reduces inflammation and nerve damage (62).
Studies have shown that Zeposia is more effective than Avonex in reducing the amount of new active lesions on MRI and at reducing brain volume loss. Higher dose Zeposia was shown to reduce relapse rate significantly compared to Avonex (63).
It is taken as a tablet, once a day. The dosage is gradually increased over a period of eight days to help lessen the occurrence of side effects (62).
Bristol Myers Squibb
Zeposia can be prescribed for people with active RRMS, for MS patients in Scotland only (64).It is currently not recommended by NICE to treat people with MS in the rest of the UK nations.
The most common side effects are an increased risk of infection including coughs, colds, respiratory infection, lowered blood pressure, slowed heart rate and increased liver enzyme levels. Those taking Zeposia should have their blood pressure checked regularly (62).
Once diagnosed with MS, your neurologist will talk to you about any medication you may require and be eligible for. They should discuss with you all of your possible options. One thing to consider when looking at these medications is your lifestyle and how the administration of these drugs will fit into your day-to-day living. There are several factors you may want to consider and discuss with your family and neurologist. Examples may include,
Openly discuss all of the options with your MS nurse and/or neurologist to come to a decision on what the best course of treatment is for you.
More information The MS Trust website has a useful tool called ‘MS Decisions aid’ which allows you to compare different DMTs to help you find the one that is most suitable for you.
The side effects of DMTs will differ with each therapy and vary from person to person. It is important to talk to your MS nurse or neurologist about any concerns you may have.
Side effects are generally not severe and there are various ways to manage them. For example, if you experience flu-like symptoms after injecting, try changing the time of day that you take your injection, possibly to just before bedtime so you can sleep through the side-effects.
Alternatively, providing they do not interfere with any other medication you are taking, it is recommended that you take paracetamol or ibuprofen two hours before the injection to ease the symptoms.
If you have injection-site reactions, you could try using Emla cream which numbs the area prior to the injection. Always rotate the injection site to avoid using the same area each time. It may also help to ensure that the drug is at room temperature and also to warm your skin before injecting.
If you are taking any of the oral therapies, ask your MS nurse how to manage any side effects you are experiencing.
If the side effects become severe or you feel unable to cope with them, contact your MS nurse or neurologist who will be able to provide further support. Contact the MS-UK Helpline if you need help to find your nearest MS nurse.
While you may be eligible for DMTs it is entirely your choice whether you wish to take them or not. Should you wish not to, this may be referred to as being ‘drug naïve’ by health professionals. If you choose not to take a DMT it would be useful to keep a symptom diary in case you change your mind in the future.
More information Our range of Choices booklets offer more information about the different ways which can help you to manage the impact of MS, incorporating diet, exercise and complementary therapies.
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