The necessity for early treatment in MS is becoming increasingly clear. The time has passed for the “wait and see how it goes” attitude before treatment is started. Studies indicate that early treatment delays disability, presumably by decreasing the injury to the nervous system caused by the disease.
The treatment of MS generally falls into two categories: treatments that address symptom management, and treatments that change the course of the disease by modifying the number and severity of attacks and the progression of disability. There has been a significant progress in both types of treatments in the last decade. Six different products have been approved by the FDA as disease modifying treatments for MS since 1993. These included three interferon-beta products (Betaseron®, Avonex®, and Rebif®) and three unrelated products (Copaxone®, Tysabri®, Novantrone®).
Interferon-Beta products
Betaseron® (interferon beta-1b) was the first beta interferon to be approved and marketed in the USA. As with all beta-interferons, it shuts down the inflammation of MS lesions through various mechanisms including repairing the blood brain barrier and reducing the inflammatory process in the lesions. Betaseron decreases relapse rate, increases time between attacks, decreases the severity of attacks, while decreasing the amount of accumulated lesions seen on MRI. Betaseron is given every other day by means of subcutaneous injection (under the skin) providing the highest dose of interferon-beta available for treatment of MS. Betaseron is approved for relapsing-remitting MS, and a recent European study showed some efficacy in secondary progressive MS. Marketed by Berlex Laboratories, Inc.
Avonex® (interferon beta-1a) has been shown to slow the rate of progression of disability in relapsing-remitting MS. It has been demonstrated to decrease the relapse rate and the amount of accumulated damage seen on MRI, but to a lesser extent than other available agents. Avonex is given as weekly intramuscular injection at a lower dose than Betaseron or Rebif. Avonex is indicated for the treatment of relapsing-remitting MS. Marketed by Biogen, Inc.
Rebif® (interferon beta-1a) is identical in chemical structure to Avonex. However it is given in subcutaneous rather than intramuscular injections, and in higher and more frequent doses than Avonex. Rebif is effective in reducing the number and severity of relapses, delaying the progression of disability, and reducing the number of new and accumulated lesions seen on MRI. Rebif has been used in Europe and Canada for over five years but was only recently approved by the FDA for use in the US after a head-to-head comparison to Avonex (the EVIDENCE study) showed superiority of Rebif in all clinical and MRI outcome measures. It is approved for use in relapsing-remitting MS. Rebif is available in pre-filled syringes. Marketed by Serono, Inc.
Glatiramer Acetate
Copaxone® (glatiramer acetate) is different from beta interferon in chemical structure and mechanisms of action. It consists of a group of amino acids that looks something like myelin itself. It acts by suppressing the immune system's attack on myelin and possibly other mechanisms. It decreases the frequency and severity of attacks to the same extent as Betaseron and Rebif, but with slightly less effect on MRI lesions. Copaxone is administered daily by subcutaneous injection and is used for relapsing-remitting MS. A pre-filled syringe is available for ease of use. Marketed by Teva Neuroscience.
A Monoclonal Antibody
Tysabri (natalizumab) is the first humanized monoclonal antibody approved for the treatment of MS. Tysabri works by blocking the receptors on white blood cells that allow them to enter the brain and spinal cord. Keeping these cells out leads to a decrease in inflammation. Tysabri is administered by IV infusion once every four weeks. In 2004, one year’s data showed that Tysabri slows the progression of disability, has a positive effect on MRI, and those taking the drug could experience a two-thirds reduction in MS relapse rate, about double the benefits offered by other MS drugs. Tysabri can only be prescribed, distributed, and infused by prescribers, infusion centers, and pharmacies registered with the TOUCH Prescribing Program developed by Biogen Idec and Elan, manufacturers and distributors of the drug, in consultation with the FDA. The drug should be used as a montherapy in patients who have not responded adequately to or who cannot tolerate the other disease-modifying drugs.
Mitoxantrone
Novantrone® (mitoxantrone) is a reasonably nontoxic chemotherapy agent that slows disease progression in MS and lessens the number of relapses through its ability to suppress the activity of T cells and B cells. These white blood cells attack the myelin that protects nerve cells, and by doing so cause the scarring associated with MS. It is approved for worsening MS including secondary progressive and relapsing-remitting forms of the disease. It is usually used for a limited period of time and with a limited total number of doses. A cardiac evaluation should be done prior to starting this drug. Novantrone is typically administered intravenously once every three months for two years. Marketed by Immunex Corporation.
Steroid Treatment
For acute exacerbations, steroids have been reported to shorten the duration of acute attacks by lessening the swelling and inflammation in MS lesions. However they do not alter the frequency of exacerbations or the progression of the MS, and long term use should be avoided except in selected patients. Included are synthetic adrenal glutcocorticoids (corticosteroids) such as prednisone, prednisolone, methylprednisolone, betamethasone, and dexamethasone.
Conclusion
The treatment of MS has changed dramatically in the last decade. A more favorable outcome and better quality of life are definitely more attainable by people with MS through appropriate and aggressive management. Such management should consider all available options including: the medications mentioned above, symptomatic treatments, medical, rehabilitative and psychological approaches, alternative treatment options, and experimental treatments available through clinical trials in specialized MS centers. Your individual physician should be able to provide more detailed information and advise you regarding the suitability of these available options considering the current condition of your disease.
Remember, EARLY TREATMENT MAKES A DIFFERENCE.
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(Last reviewed 7/2009)