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MS is a tough disease!

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  Multiple Sclerosis Treatments

What drug treatments are available for MS and its symptoms?

Below is a table of drugs used to treat multiple sclerosis and its symptoms. It only lists drug therapies and does not deal with other forms of therapy - These shall be posted to this section in a short period of time.

It is vital that you are prescribed and take any of these medications in consultation with a fully qualified medical practitioner who is familiar with your case history. Many of these drugs have potentially serious side-effects especially in combination with other medications.

The list is by no means complete and new treatments are being researched and coming into use all the time. It should be emphasized that none of these drugs are a "cure" for either MS nor for any of its symptoms. The only medications available at the moment either slow down the course of the disease at best or are palliative on its symptoms.
 
 

ABC Treatments

Condition/Symptom

Generic Name

Comments

Brand Name

Manufacturer

Relapsing-Remitting MS, Secondary Progressive MS with relapses

Interferon Beta 1a

30 mcg intramuscular once per week self-injection

Avonex

Biogen

44 mcg subcutaneous 3 times per week self-injection

Rebif

Ares-Serono

Interferon Beta 1b

Subcutaneous self-injection once every two days

Betaseron

Berlex

Betaferon

Schering

Relapsing-Remitting MS

Glatiramer Acetate

20mg subcutaneous daily self-injection

Copaxone

Teva-Marion

Chemotherapeutic Agents

Condition/Symptom

Generic Name

Comments

Brand Name

Manufacturer

Secondary Progressive MS, Worsening Relapsing-Remitting MS

Mitoxantrone

Intravenous every 3 months for about 2 to 3 years

Novantrone

Immunex

Potential, unlicensed treatments for Secondary Progressive MS and Worsening Relapsing-Remitting MS

Azathioprine

Anti-cancer treatments - currently unlicensed for use with MS

Imuran

Glaxo-Smith-Kline

Cyclophosphamide

Anti-cancer treatments - currently unlicensed for use with MS

Cytoxan, Neosar

Bristol-Myers Squibb

Cyclosporine

Anti-cancer treatments - currently unlicensed for use with MS

Sandimmune

Novartis Pharma

Methotrexate

Anti-cancer treatments - currently unlicensed for use with MS

generic

Mylan

Cladribine

Anti-cancer treatments - currently unlicensed for use with MS

Leustatin

 

Corticosteroids & ACTH

Condition/Symptom

Generic Name

Comments

Brand Name

Manufacturer

Acute relapses in Relapsing-Remitting MS and occasionally Secondary Progressive MS

MethylPrednisolone

Intravenous high doses tapered off

Depo-Medrol

 

Solu-Medrol

Pharmacia

Prednisone

Oral administration

Deltasone

Pharmacia

Prednisolone

Intravenous administration

Delta-Cortef

Pharmacia

Dexamethasone 

 

Oral administration

Medrol

Pharmacia

Decadron

Merck

Adreno-corticotrophic Hormone (ACTH), Corticotropin

Use largely replaced by synthetic corticosteroids

Acthar

Roche, Rhone-Poulenc Rorer

Pain/Altered Sensation (Dysaesthesia)

Condition/Symptom

Generic Name

Comments

Brand Name

Manufacturer

Neuropathic/neurogenic pain (pain that arises from nerve dysfunction and not as a result of injury e.g. Trigeminal Neuralgia)

 

 

 

 

 

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Carbamazepine

Anti-convulsant

Tegretol, Epitol, Atretol, Carbatrol

Ciba

Gabapentin

Anti-convulsant

Neurontin

Pfizer

Topiramate

Anti-convulsant

Topamax

Ortho-McNeil

Zonisamide

Anti-convulsant

Zonegran

Elan

Phenytoin

 

Dilantin

 

Desipramine

 

Norpramin

 

Amitriptyline

Tricyclic antidepressant

Elavil

AstraZeneca

Imipramine

Tricyclic antidepressant

Tofranil, Imavate, Janimine

Ciba Geigy

Doxepin 

Tricyclic antidepressant

Sinequan, Adapin, Triadapin, Zonalon

 

Protriptyline

Tricyclic antidepressant

Vivactil

 

Cannabis and synthetic cannabinoids

Illegal in many parts of the world

Marinol

 

Pain associated with poor circulation

Pentoxifylline

 

Trental

 

'flu-like symptoms associated with Beta Interferon injections 
 
 
 
 

 

Ibprofen 

 

 

Neurofen 

 

US versions 

 

Aspirin 

 

generic 

 

Acetaminophen 

Often formulated with alkaloid pain killers like codeine and hydrocodone

generic

 

Paroxysmal itching

Hydroxyzine

 

Atarax

 

Depression/Anxiety/Insomnia

Condition/Symptom

Generic Name

Comments

Brand Name

Manufacturer

Depression without anxiety

Fluoxetine

SSRI

Prozac

Eli Lilly

Mild anxiety, panic attacks, people on multiple medications 

 

Sertraline

SSRI 

 

Zoloft

Pfizer

Lustral

Pfizer

Moderate depression, anxiety, people for whom other antidepressants don't work

Venlafaxine

SSRI

Effexor XR

Wyeth-Ayerst Laboratories

Depression with mild anxiety

Citalopram

SSRI

Celexa

Forest Pharmaceuticals

Depression with mild anxiety

Parocetine

SSRI

Paxil, Seroxat

Glaxo-Smith-Kline

Depression also agoraphobia,  insomnia,  essential tremor, some pain syndromes

Trazodone

Similar to SSRIs - works by increasing the amount of serotonin

Desyrel,  Trialodine

Pharmacia

Depression

Amitriptyline

Tricyclic antidepressant

Elavil

AstraZeneca

Endogenous depression 

Nortriptyline

Tricyclic antidepressant

 

Pamelor

Novartis

Aventyl

Eli Lilly

Depression

Imipramine

Tricyclic antidepressant

Tofranil, Imavate, Janimine

Ciba Geigy

Depression particularly when accompanied by anxiety and insomnia

Dothiepin 

Tricyclic antidepressant

Prothiaden

Knoll Pharmaceuticals

Depression of varying severity with coexisting anxiety

Lofepramine

Tricyclic antidepressant 

Gamanil

Organon

Anxiety, neurosis, manic depression

Doxepin 

Tricyclic antidepressant

Sinequan, Adapin, Triadapin, Zonalon

 

All types of depression, apathety, withdrawl

Protriptyline

Tricyclic antidepressant

Vivactil

 

Moderate to severe depression

Tranylcypromine

Monoamine oxidase inhibitor (MAOI)

Parnate

Glaxo-Smith-Kline

Depression particularly when accompanied by social phobia

Moclobemide

Monoamine oxidase inhibitor (MAOI)

Manerix, Aurorix

Roche

Withdrawn, depression-related fatigue, concentration and attention problems, depression-related sexual dysfunction

Bupropion

Aminoketone antidepressant

Wellbutrin SR

Glaxo-Smith-Kline

Amfebutamone

 

Depression with significant anxiety, panic attacks, insomnia, sexual dysfunction

Nefazodone

Phenylpiperazine antidepressant 

Serzone

Bristol-Myers Squibb

Depression with insomnia, moderate to severe anxiety, sexual dysfunction

Mirtazapine

Piperazino-azepine antidepressant 

Remeron

Organon

Insomnia

Zolpidem

Imidazopyridine 

Ambien

Pharmacia

Anxiety - not indicated if primary complaint is depression

Alprazolam

Benzodiazepine - addictive

Xanax

Pharmacia & Upjohn

Insomnia, Anxiety

Temazepam

Benzodiazepine - addictive

Restoril

Novartis

Anxiety, Insomnia, muscle relaxant

Diazepam

Benzodiazepine - addictive

Valium

Roche

Anxiety

Buspirone

Azaspirodecanedione

BuSpar 

Bristol-Myers Squibb

Fatigue

Condition/Symptom

Generic Name

Comments

Brand Name

Manufacturer

Multiple sclerosis fatigue. Also dystonia and akathisia

Amantadine

Anti-viral 

Symmetrel

Endo Pharmaceuticals

 Fatigue

Pemoline

Central Nervous System stimulant

Cylert

 

Modafinil

 

Provigil

 

Urinary Problems

Condition/Symptom

Generic Name

Comments

Brand Name

Manufacturer

Urinary Frequency and Urgency

Oxybutynin

 

Ditropan XL

 

Desmopressin, Vasopressin

Nasal spray

DDAVP

 

Urinary Urgency and Incontinence

 

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Tolterodine

 

Detrol

 

Carbamazepine

Anti-convulsant

Tegretol, Epitol, Atretol, Carbatrol

Ciba

Imipramine

 

Tofranil

 

Bethane

 

Urecholine

 

Urinary Hestitancy

Phenoxybenzamine

 

Dibenzyline

 

Terazosin

 

Hytrin

 

Spastic Bladder

Propantheline

Anticholinergic agent

Pro-Banthine 

 

Oxybutynin

Anticholinergic agent

Ditropan

 

Hyoscyamine

Anticholinergic agent

Urispas

 

Cystopas

 

Baclofen

Sceletal muscle relaxant 

Lioresal

 

Diazepam

Benzodiazepine - addictive

Vallium

 

Urinary Tract Infections (UTI)

Methenamine

 

Hiprex

 

Mandelamine

 

Nitrofurantoin

 

Macrodantin

 

Phenazopyridine

 

Pyridium

 

Ciprofloxacin

 

Cipro

 

Bowel Problems

Condition/Symptom

Generic Name

Comments

Brand Name

Manufacturer

Constipation

Bisacodyl

Stimulant laxative 

 

Dulcolax 

 

Bisacolax 

 

Magnesium hydroxide (Milk of Magnesia)

Hyperosmotic laxative

generic

 

Glycerin

Hyperosmotic laxative, suppository

Sani-Supp 

 

Psyllium hydrophilic mucilloid 

Bulk-forming oral laxative

Metamucil

 

Sodium phosphate 

 

Fleet Enema

 

Docusate

Stool Softener 

Colace

 

 

Suppository 

Therevac Plus

 

Sexual Dysfunction

Condition/Symptom

Generic Name

Comments

Brand Name

Manufacturer

Erectile dysfunction in men and women

Sildenafil

 

Viagra

 

Erectile dysfunction

 

Alprostadil 

Suppository 

Prostin VR

 

 

MUSE

 

Papaverine

Injection into penis

 

 

Spasticity/Clonus/Muscle Tics

Condition/Symptom

Generic Name

Comments

Brand Name

Manufacturer

Spasticity

Diazepam

Benzodiazepine 

Valium

 

Clonazepam

Benzodiazepine

Klonopin

 

Rivotril

 

Baclofen

Sceletal muscle relaxant 

Lioresal

 

Dantrolene sodium 

Sceletal muscle relaxant

Dantrium

 

Tizanidine

Sceletal muscle relaxant

Zanaflex

Elan

Sirdalud

 

Clonidine

Antihypertensive

Catapres

 

Botulinum Toxin

Kills Nerves 

Botox, Neurobloc

, Elan

Tremor

Condition/Symptom

Generic Name

Comments

Brand Name

Manufacturer

Postural tremor 
 
 
 
 
 
 
 
 

 

Clonazepam

 

Klonopin

 

Rivotril

 

Gabapentin 

 

Neurontin

 

 

Beta blockers 

 

 

Primidone 

 

Mysoline 

 

Botulinum toxin 

Kills Nerves 

 

 

Acetazolamide 

 

Diamox 

 

Rest tremor 

 

Levodopa­carbidopa 

 

Sinemet 

 

 

anticholinergics

 

 

Tremor

Isoniazid

 

Laniazid

 

Nydrazid

 

Vertigo, Nausea, Dizziness

Condition/Symptom

Generic Name

Comments

Brand Name

Manufacturer

Vertigo, Nausea, Dizziness

 

 

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Meclizine

 

Antivert

 

 

Bonamine

 

Dimenhydrinate

 

Dramamine

 

Prochlorperazine

 

Compazine 

 

Scopolamine

 

Transderm

 

Diphenhydramine

 

Benedryl

 

Anti-virals/Vaccinations

Condition/Symptom

Generic Name

Comments

Brand Name

Manufacturer

Prevention of Relapses

'flu jabs

Now recommended for people with MS

N/A

N/A

 

Acyclovir

 

 

 

Other Treatments/Experimental Medications

Condition/Symptom

Generic Name

Comments

Brand Name

Manufacturer

Relaspsing-Remitting Multiple Sclerosis and possibly Secondary Progressive MS

Natalizumab

Monoclonal antibody - blocks access for  lymphocytes to the  central nervous system

Antegren

Elan/Biogen

Relaspsing-Remitting Multiple Sclerosis and Secondary Progressive MS

Alemtuzumab

Monoclonal antibody - kills T Cells

Campath-1H

Schering/Millennium Pharmaceuticals/ILEX Oncology

 

4-aminopyridine

Blockspotassium channels in neurons which may improve nerve transmission in MS 

Fampridine

Elan/Accorda

 

3,4 Diaminopyridine

Blocks potassium channels in neurons which may improve nerve transmission in MS

 

 

 

Eliprodil

Might promote remyelination

 

 

 

IV Immunoglobin

Reduces severity of viral infections

Gammagard, Gammar-IV, Gamimune N, Iveegam, Panglobulin, Sandoglobulin, Venoglobulin

 

 

 

May reduce severity of relapses

AnergiX-MS

Anergen

Neuropathic pain

Pregabalin

Concerns raised over safety because of tumours in mice

 

Pfizer

Chronic pain 

Ziconotide 

Non-opioid, calcium channel blocker

 

Elan/Neurex 

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"Is there a cure for MS?"

Sadly not - currently there is no cure for MS but there are treatments both to slow down the course of the disease and mitigate against its effects. There are a number of new treatments that are in the research stage or are in clinical trials. Some of these are very promising indeed and the current mood in MS research is very optimistic - we can look forward to more effective treatments in the near future.

ABC Treatments

Perhaps the most effective treatments currently available today deal with the autoimmune component of multiple sclerosis and work by regulating aspects of the immune system. They are known as the "ABC" treatments, where "A" stands for Avonex, "B" stands for Betaseron/Betaferon and "C" stands for Copaxone. Avonex and Betaseron are both varieties of beta interferon. A third drug, Rebif, is also beta interferon. ABCR would be a more accurate acronym though clearly less appealing to those of us with a crossword-solving mentality. Copaxone is a completely different drug altogether - the active ingredient being glatiramer acetate, Co-polymer-1 or COP-1.

A fifth drug, Novantrone, has recently become available. This is a chemotherapeutic agent which I shall deal with in a later section.

Beta interferon

Beta Interferon comes in two varieties, beta interferon-1a (Avonex and Rebif) and beta interferon-1b (Betaseron in the US and Betaferon in Europe).

Beta interferon (IFN-b) is a naturally occurring biochemical in the human body and belongs to a group of biochemicals known as interferons (IFNs) which regulate the functioning of the immune system. The mechanism by which IFN-b functions is complex and not fully understood. I shall explore this more fully in a later section but for now we can summarize it as:

  • It reduces the levels of another interferon, called interferon gamma (IFN-g), which is known to be associated with the disease process in multiple sclerosis.
  • It appears to block certain white blood cells from attacking the insulating sheaths of the nerves - the myelin sheaths.
  • It appears to stop a type of white blood cell, called a T Cell, from releasing immune system signaling molecules (cytokines) that would otherwise encourage inflammation.
  • It appears to interfere with the process of summoning new immune system cells to the site of inflammation.

How effective is IFN-beta?

A lot of studies have now been done on the efficacy of beta interferons in both relapsing-remitting and secondary progressive MS. The methods of evaluation that have been used are measurements of MRI lesion activity, relapse rate and EDSS (degree of disability). The bottom line of this research is that the drug is effective at reducing relapses and burden of disease under MRI in both types of MS. Most studies imply that the drugs also affect long-term progression though the evidence for this is less clear. Most studies also imply that IFN-b is dose dependent - that is, the higher the dose used, the greater the efficacy [Durelli et al, 2001; Coyle, 2002; Ref 1998]. However, one study contradicts these findings [Ref, 2001].

Before going into the statistics thrown up by these studies I'd like to address what seems to me to be a very important misconception that's been floating around the MS community. People who are using beta interferon (or Copaxone, for that matter) sometimes believe that the drug is not working for them because their disease continues to progress. Others say that the drug only works for one third of users. The first of these statements is probably incorrect and the second is almost definitely wrong.

In the first place, we know that MS is a very unpredictable disease and none of us know where, nor on what time scale it is heading. If it continues to progress while you are using IFN-b, that doesn't mean that the drug isn't working - it could have progressed faster if you hadn't been using it. In fact, this is the implication of the studies.

Secondly, when research shows an x% reduction in the burden of new lesions between the people being treated with IFN-b as compared to a placebo group (those not receiving the drug) over a one year period, it is very hard to tell whether it has worked fully for some people, partially for some others and not at all for the rest. This is because no one has any idea of what would have happened to any particular person. Unless the studies are extremely large, all that can be said is that the drug reduces lesion load by an average of x% over a certain period of time.

It may be that the ABCR drugs don't work for everybody and, indeed, some other people seem to do very well with them whereas others do not. However, at this point in time, it's very difficult to say whether this is due to the drugs, the individuals or the interaction between the two. Probably, the best advice is to switch medication from one to another or to Novantrone if your disease seems to be running out of control.

What IFN-b is not, is a cure for some people and no good at all for others. The bottom line is that, even if it doesn't appear to be working for you, it may very well be.

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But how effective is beta interferon? Gimme some numbers!

In relapsing-remitting MS the number of relapses and their severity is reduced by 25% and upwards, depending on the dose. The reduction in lesion load measured on MRI scans is much greater than this at upwards of 70%. It is believed that the minority of lesions detectable on MRI scans produce clinically measurable symptoms, but the benefits of these massive reductions may pay dividends years later after onset of a secondary progressive phase.

One recent hotly-disputed study [Coyle, 2002] has showed that interferon beta 1a administered according to the Rebif regime is more effective than the same compound administered according to the Avonex regime. Another study [Durelli et al, 2001] has shown that interferon beta 1b administered according to the Betaseron regime is more effective than interferon beta 1a administered according to the Avonex regime.

In one study, IFN-b, was shown to reduce the relapse rate in secondary progressive multiple sclerosis by a statistically significant amount. However, two other similar studies failed to show statistically significant effects. It is known that relapse rate falls off during the course of the disease and that inflammatory activity is correlated with relapses. It is also believed that the mechanism of disease activity changes from an inflammatory one to a neuro-degenerative one during the secondary progressive phase of the disease. Based on these and other results, it seems likely that IFN-b is only effective at preventing inflammation and thus relapses and not effective at preventing neuro-degeneration.

Long term studies show that, for most people, beta interferons continue to be effective with continued use during the relapsing-remitting phase of the disease. However, a sizeable minority of patients develop neutralising antibodies to the drugs which may reduce their efficacy.

Are there any side-effects of beta interferon?

Five year studies of beta interferon use have turned up no serious side-effects. This has always struck me as strange. T-cell mediated immunity is vital for survival - look at AIDS to see what happens if you don't have any T-cells. However, some people genetically lack the ability to produce any gamma interferon at all and this apparently has no effect on their life-expectancy (presumably none of them get MS or at least not very badly).

Avonex appears to give fewer side effects than Betaseron or Rebif, perhaps due to its lower dose - injections are once a week as opposed to every other day or three times per week.

The principle side-effect of beta interferon use are 'flu-like symptoms - fever, night sweats and muscle aches. These can be very unpleasant but often subside after a few months and respond well to ibuprofen.

Liver toxicity has been noted in some patients particularly at higher doses though this symptom is usually mild. Be sure to notify your doctor if you are experiencing new symptoms whether or not they appear to be attributable to multiple sclerosis.

Depression is another potential side-effect.

Injection site reactions can also be a problem and it is advisable to rotate the injection site to mitigate against these. Numbing the skin at the injection site with ice, getting the drug up to room temperature before injecting and taking antihistamines before injecting all help.

One of the difficulties many people have is the problem of having to inject themselves. Autoinjectors are available or you can get someone else to help you with this. Most people get over this barrier eventually.

Copaxone, glatiramer acetate, COP-1

Glatiramer acetate is a collection of synthetic peptide strings derivatives that is believed to work by modifying the body's T-cell mediated immune response to myelin. As with beta interferon, its method of action is complex and is not fully understood. One theory goes that, by flooding the body with the antigens similar to those in proteins found in the myelin sheath, the drug acts as a decoy and draws some of the attack away from the CNS.

Glatiramer acetate arose from studies done on mice. They were first infected with EAE, an experimentally induced disease that resembles multiple sclerosis. The mice were then injected with the drug and responded well to the treatment.

Glatiramer acetate is manufactured under the brand name Copaxone by Teva Marion Partners. It was known as copolymer during its development phase which became copolymer-1 (COP-1) when copolymer-2 started to be developed.

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How effective is Copaxone?

Copaxone is about as effective as beta interferons. There have been two double blind studies both over two years and both done on relapsing/remitting patients. The first was at a single site and reported a 75% reduction in relapse rate, the second multi-site study reported a 29% reduction in relapse rate. The wide discrepancy between the two studies is probably explained by the widely fluctuating results deriveable from the relatively small population bases that make up such trials. The first single-centre trial was done with 25 patients receiving glatiramer acetate and 25 receiving a placebo. The second multi-centre one had 125 receiving the drug and 126 the placebo.

The initial trials also indicated a reduction in EDSS progession in multiple sclerosis. More recent evidence has shown Copaxone to significantly reduce the rate of brain atrophy. The results of a contraversial and disputed comparative trial between Avonex, Betaseron and Copaxone were released in 1999. These indicated that Copaxone was as effective as Betaseron and more so than Avonex.

What are the side-effects of Copaxone?

Copaxone is generally better tolerated than beta interferon, though as a synthetic drug that doesn't occur naturally in the human body and with a track record of only a few years, it is hard to evaluate its long-term effects. However no serious side-effects have been reported thus far.

Copaxone is injected sub-cutaneously on a daily basis. The most common problem that users have are injection site reactions which include itching and inflammation. These reactions can be mitigated against by revolving the injection site, preparing it with ice and ensuring that the drug is at room temperature before injecting.

Some users experience flushing, chest and joint pains, weakness, nausea, anxiety and muscle stiffness. These tend to resolve after about a quarter of an hour without special treatment.

Availablity of ABC treatments

ABC treatments are very expensive, but they are available to ALL those with MS.  Talk to your neurologist.  Each manufacturer has a funding program if you are uninsured, or if your insurance won’t pay for it.

There isn't much that works for MS, but these drugs do and we need to preserve our myelin until newer and better treatments become available. The huge reduction in "silent" lesions (those which are not associated with clinical symptoms) observed with the use of ABCRs seems to me to bode well for the longer term prognosis of MS.

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