Disease-modifying therapies, steroids, and drugs that relieve particular symptoms all play a role in the management of MS.

By Joseph Bennington-CastroMedically Reviewed by Jason Paul Chua, MD, PhDReviewed: December 3, 2021

Several different types of medication may be prescribed to people who have multiple sclerosis (MS).

Disease-modifying therapies (DMTs) can prevent acute MS attacks, or relapses, and slow the progression of the disease, thereby preventing physical and cognitive disability. Other drugs, primarily corticosteroids, are used to help control severe symptoms during relapses.

There are also numerous drug treatments for managing ongoing symptoms associated with multiple sclerosis, such as pain, tremors, walking difficulty, and muscle spasticity.

Disease-Modifying Therapies for MS

Disease-modifying drugs are sometimes called “immunomodulators,” because they affect the functioning of the immune system. They do not make you feel better in the short term, nor do they address specific MS symptoms. But they are effective at slowing the progression of disability caused by multiple sclerosis and lowering the frequency and severity of acute attacks in people who have the most common type of the disease, known as relapsing-remitting MS (RRMS), as well as those with so-called active secondary-progressive MS (SPMS).

Disease-modifying therapies also reduce the development of new lesions (areas of damage, or scarring, in the brain and sometimes spinal cord), as seen on MRI (magnetic resonance imaging) scans.

Some DMTs are more effective than others at slowing disability progression, but the more effective drugs also tend to have more, or more serious, side effects. That’s why people diagnosed with MS and their doctors need to work together to find the right benefit-to-risk balance when selecting a DMT.

Secondary-progressive MS (SPMS) is a second phase of RRMS, during which a person usually has fewer relapses but disease progression still occurs, accompanied by increased disability. Until recently, only one drug, Novantrone (mitoxantrone), was approved for use in people with SPMS. But since 2019, several more have been approved for “active” SPMS, or SPMS in which relapses still occur and new lesions are seen on MRIs.

For people with primary-progressive MS (PPMS), in which the disease progresses and disability worsens without either noticeable relapses or periods of improvement, only one disease-modifying medication, Ocrevus (ocrelizumab), has been shown to lower the risk of disability progression.

Drugs Approved for Relapsing-Remitting MS

The U.S. Food and Drug Administration (FDA) has approved the following drugs to treat relapsing-remitting MS:

• Aubagio (teriflunomide) is a once-daily capsule that blocks the production of immune-system cells.
• Avonex and Rebif (interferon beta-1a) and Betaseron and Extavia (interferon beta-1b) are injected into the muscle (intramuscular) or under the skin (subcutaneous). It’s believed that these drugs work by controlling inflammation in the central nervous system (CNS).
• Copaxone (glatiramer acetate) is a subcutaneous injection that attracts immune-system cells (T cells) that would otherwise attack myelin sheaths.
• Gilenya (fingolimod) is a once-daily pill that prevents T cells from getting out of lymph nodes and into the bloodstream. In December 2019, the FDA approved three applications for generic versions of Gilenya.
• Glatopa (glatiramer acetate) is considered a generic equivalent of Copaxone.
• Plegridy (peginterferon beta-1a) is a longer-lasting form of interferon.
• Tecfidera (dimethyl fumarate) is a twice-daily oral capsule that lowers CNS inflammation and the ability of immune cells to get into the CNS. A generic version of Tecfidera is available in the United States.
• Tysabri (natalizumab) is an intravenous (IV) infusion that works by binding to white blood cells and interfering with their movement from the bloodstream into the CNS.

Drugs Approved for RRMS and SPMS

• Bafiertam (monomethyl fumarate) works similarly to Tecfidera and Vumerity and is also taken as a twice-daily capsule.
• Kesimpta (ofatumumab) is a self-administered subcutaneous injection that’s taken once a month using a prefilled auto-injector pen. Like Ocrevus, Kesimpta depletes CD20-positive B lymphocytes, a type of white blood cell believed to be involved in the autoimmune process that leads to the development and progression of MS.
• Mavenclad (cladribine) is an oral pill, taken in two 10-day courses, one year apart. It works by killing T and B cells, preventing them from damaging the nerves in the brain and spinal cord.
• Mayzent (siponimod) is an oral pill taken once daily that works similarly to Gilenya. It is also approved for clinically isolated syndrome, which is a single episode of MS-like symptoms that is sometimes the first sign of MS.
• Novantrone (mitoxantrone) is an immunosuppressant drug administered by IV infusion. It requires regular cardiac monitoring, and there is a total maximum amount an individual can receive over their lifetime.
• Ponvory (ponesimod) is an oral tablet taken once daily that works similarly to Gilenya, Mayzent, and Zeposia. It’s approved for treatment of clinically isolated syndrome, as well as for relapsing-remitting MS and active secondary-progressive MS.
• Vumerity (diroximel fumarate) is an oral capsule that’s taken twice daily and that works similarly to Tecfidera, but is believed to cause fewer gastrointestinal side effects than Tecfidera. Vumerity is also approved to treat clinically isolated syndrome.
• Zeposia (ozanimod) is an oral capsule, taken once daily, which is approved to treat RRMS, SPMS, and clinically isolated syndrome. Zeposia is one of a class of drugs known as S1P receptor modulators, which sequester cells within lymph nodes, thereby preventing them from entering the central nervous system and causing inflammation.

Drug Approved for Relapsing MS and for PPMS

• Ocrevus (ocrelizumab) is an intravenous (IV) infusion that works by targeting CD20-positive B lymphocytes and destroying them. It’s the only drug approved by the FDA for PPMS.

Second-Line Therapy for Relapsing MS

The FDA has also approved the IV drug Lemtrada (alemtuzumab) for people who have forms of MS that include relapses and who haven’t responded well to two or more types of disease-modifying medication.

Alemtuzumab works by rapidly depleting the body’s supply of immune (T and B) cells, which temporarily stops the immune-system effects on your CNS and allows your body to create new cells, which might not attack myelin sheaths.

The FDA recommends using it only as a second-line therapy (after other drugs have failed) because it increases the risk of complications, including severe infections, development of new autoimmune diseases, and other potentially dangerous conditions.

RELATED: 10 Key Questions About Multiple Sclerosis Drugs

Off-Label RRMS Treatment

The monoclonal antibody Rituxan (rituximab), which is considered a high-efficacy MS treatment, is not approved to treat MS in the United States but is sometimes prescribed off-label to treat RRMS. It is administered intravenously in a healthcare setting.

Rituxan works similarly to Ocrevus, targeting CD20-positive B lymphocytes and destroying them.

MS Medication Side Effects

All drugs can have adverse side effects; those associated with MS medication can range from mild to serious.

Mild side effects include irritation at an injection site (for drugs that are injected or infused) and flu-like symptoms following injections of the interferon beta drugs Betaseron, Extavia, Avonex, Rebif, and Plegridy.

Interferon beta medication can also cause depression as a side effect.

Many MS drugs raise the risk of infection — and infection, in turn, can worsen MS symptoms. While not all infections can be prevented, it’s important to be aware of this risk and keep an eye open for signs and symptoms of infection.

Of particular concern during the COVID-19 pandemic is that taking certain DMTs may reduce an individual’s response to the available COVID-19 vaccines. According to the National Multiple Sclerosis Society, people with MS who use the following DMTs may benefit from a third dose of an mRNA vaccine to raise the likelihood of their mounting an immune response against COVID-19:

• Gilenya, Mayzent, Zeposia, or Ponvory
• Lemtrada
• Ocrevus, Kesimpta, Rituxan, and biosimilars

The most serious potential side effect of certain MS drugs is progressive multifocal eukoencephalopathy (PML), a viral infection of the brain associated with the JC (John Cunningham) virus. Among MS drugs, Tysabri is associated with the highest risk of PML. 

Learn More About Side Effects of Multiple Sclerosis Medications

Treatments for Acute Attacks

For MS relapses, especially severe ones that interfere with a person’s mobility, safety, or ability to function, doctors may prescribe short-term, high-dose corticosteroids.

These drugs help shorten recovery time by reducing inflammation in the body.

Examples of corticosteroids include:

• Decadron (dexamethasone)
• Deltasone (prednisone)
• Solu-Medrol (methylprednisolone)

Steroids are typically given intravenously for three to five days, and may be followed by a tapered dose of an oral steroid over one to two weeks.

RELATED: 6 Side Effects of MS Steroid Treatment

People who cannot tolerate the side effects of high-dose steroids may be prescribed H.P. Acthar Gel (corticotropin), which stimulates the adrenal cortex to secrete various steroid hormones.

For people whose symptoms haven’t responded to steroids, a treatment called plasmapheresis (plasma exchange) is available.

Plasma is the liquid part of your blood, and it contains autoantibodies, a type of protein that the immune system produces to attack the body’s cells and tissues.

Plasmapheresis involves separating plasma from your blood cells and then returning the blood cells to your body along with fresh plasma or a plasma substitute.

Another possible option for treatment of MS relapses that don’t respond to steroids or that occur during pregnancy is intravenous immunoglobulin replacement therapy (IVIG). In IVIG, a product made from donated blood and containing a concentrated assortment of antibodies — proteins your body normally makes to fight infections — is administered via IV over several hours.

Drugs for MS Symptom Management

Given the wide range of symptoms caused by MS, doctors often also prescribe a variety of drugs to ease individual symptoms.

These can include:

• Ampyra (dalfampridine), an oral medication used to improve walking in adults with MS
• Analgesics (pain medication)
• Antibiotics to treat urinary tract infections (UTIs), respiratory infections, and other infections
• Anticonvulsants to treat neuropathic pain or tremors
• Antidepressants
• Antispasmodics, such as baclofen, and muscle relaxants, such as Zanaflex (tizanidine), to ease muscle spasticity
• Medication to treat gastrointestinal problems, such as nausea, ulcers, and constipation
• Nuedexta (dextromethorphan and quinidine) to treat pseudobulbar affect
• Viagra (sildenafil) and similar drugs for erectile dysfunction

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