Comparison Review of MS Drugs

 

By Editorial Team

Disease-modifying therapies (DMTs) are currently the best way to prevent relapses and slow the disability of multiple sclerosis (MS). There are several DMTs available on the market, which are listed below. When considering which treatment is best, each individual should talk to their doctor about the treatment options that are right for their unique situation, as well as all the potential benefits and risks of each treatment.¹

Treatment experiences can vary

MS is a disease that greatly varies in how it affects different people, the frequency and severity of relapses or exacerbations, the symptoms presented, and the rate of disease progression. How well a particular drug works in one person may be different from how well it works in another person. It is helpful to keep in mind these variations between people when considering which treatment to choose.

Considerations when choosing between different treatments

Common considerations when choosing between different treatments include:

• Cost
• Effectiveness in preventing new relapses
• Side effects/safety
• Route of administration

Cost of different MS treatments

Cost will vary based on each individual’s health insurance coverage and benefits. Several of the drug manufacturers have patient assistance programs that can also help cover the cost of medications.

MS treatment safety and effectiveness

All drugs that receive approval from the US Food and Drug Administration must undergo several controlled clinical trials to prove that the product is effective and safe. However, the degree of effectiveness at preventing relapses and the safety profile differ between DMTs. During some of these trials, new potential treatments may be compared to existing standard treatments, called head-to-head studies.²

Slowing down progression and reducing relapses

However, there is no one trial or source of information that compares all of the current DMTs to each other. All of the DMTs available have demonstrated through clinical trials that they reduce the frequency and severity of relapses in relapsing forms of MS, reduce the development of new MS lesions, and appear to slow down disability progression. Only one DMT, ocrelizumab (Ocrevus®), is approved for both relapsing forms and primary progressive MS (PPMS).^1,3

Comparison by route of administration

Subcutaneous injections:

• Interferon beta-1a (Rebif®)
• Interferon beta-1b (Betaseron®)
• Interferon beta-1b (Extavia®)
• Glatiramer acetate (Copaxone®, Glatopa®)
• Peginterferon beta-1a (Plegridy®)
• Ofatumumab (Kesimpta®)

Intramuscular injection:

•         Interferon beta-1a (Avonex®)

·         Peginterferon beta-1a (Plegridy®)

IV infusions:

• Alemtuzumab (Lemtrada®)
• Mitoxantrone (Novantrone®)
• Natalizumab (Tysabri®)
• Ocrelizumab (Ocrevus®)
• Ublituximab (Briumvi®)

Oral medications:

• Cladribine (Mavenclad®)
• Dimethyl fumarate (Tecfidera®)
• Diroximel fumarate (Vumerity®)
• Fingolimod (Gilenya®, Tascenso ODT™)
• Ozanimod (Zeposia®)
• Siponimod (Mayzent®)
• Teriflunomide (Aubagio®)
• Monomethyl Fumarate (Bafiertam®)
• Ponesimod (Ponvory®)

Comparison by common side effects

All medications can cause unwanted side effects. However, not all patients experience the same side effects. The side effects listed below are not all the possible side effects that these medications may cause. Individuals should talk to their doctor about what to expect and report any concerns to their doctor.^4-19

• Alemtuzumab (Lemtrada®) – Rash, headache, fever, inflammation of the nasal passages and throat, nausea, vomiting, fatigue, insomnia, red welts on skin, itching, thyroid gland disorders, joint pain, pain in arms or legs, back pain, mouth and throat pain, abdominal pain, diarrhea, sinus infection, tingling or prickling sensation, dizziness, flushing.
• Cladribine (Mavenclad®) - Upper respiratory tract infection, headache, lymphopenia
• Dimethyl fumarate (Tecfidera®) – Flushing, abdominal pain, diarrhea, nausea
• Diroximel fumarate (Vumerity®) – Flushing (developing red or hot skin), redness, itching, or rash, nausea and vomiting, diarrhea, stomach pain or indigestion
• Fingolimod (Gilenya®) – Headache, diarrhea, increased liver enzymes, cough, flu-like symptoms, sinus symptoms, infections, back pain, abdominal pain, and pain in the arms and legs
• Glatiramer acetate (Copaxone®) – Reactions at the injection site, lowered blood pressure, rash, difficulty breathing, and chest pain
• Interferon beta-1b (Extavia®) – Reactions at the injection site, flu-like symptoms, low counts of white blood cells, muscle aches, increased liver enzymes, headache, spasticity, pain, rash, difficulty sleeping, abdominal pain, depression, joint pain, and weakness or lack of energy
• Interferon beta-1a (Avonex®) – Reactions at the injection site, flu-like symptoms, low counts of white blood cells, muscle aches, increased liver enzymes, headache, spasticity, pain, rash, difficulty sleeping, abdominal pain, depression, joint pain, and weakness or lack of energy
• Interferon beta-1a (Rebif®) – Reactions at the injection site, flu-like symptoms, low counts of white blood cells, muscle aches, increased liver enzymes, headache, spasticity, pain, rash, difficulty sleeping, abdominal pain, depression, joint pain, and weakness or lack of energy
• Interferon beta-1b (Betaseron®) – Reactions at the injection site, flu-like symptoms, low counts of white blood cells, muscle aches, increased liver enzymes, headache, spasticity, pain, rash, difficulty sleeping, abdominal pain, depression, joint pain, and weakness or lack of energy
• Mitoxantrone (Novantrone®) – Nausea, hair loss, menstrual disorders (including amenorrhea), weakness or lack of energy
• Natalizumab (Tysabri®) – Headache, fatigue, joint pain, urinary tract infection, inflammation in the stomach, vaginal infection, depression, pain in arms or legs, abdominal discomfort, diarrhea, rash
• Ocrelizumab (Ocrevus®) – Infusion-related reactions
• Ozanimod (Zeposia®) – Upper respiratory infection, urinary tract infection, liver function changes, high blood pressure or changes in blood pressure when standing up (orthostatic hypotension), back pain
• Peginterferon beta-1a (Plegridy®) – Flu-like symptoms, headache, injection site reactions, blood count abnormalities, asthenia (feeling weak or tired), abdominal pain, diarrhea, nausea and vomiting, myalgia (muscle or joint pain)
• Siponimod (Mayzent®) – Headache, high blood pressure, increased liver enzymes
• Teriflunomide (Aubagio®) – Headache, diarrhea, nausea, hair loss, increased liver enzymes

Comparison by safety concerns

While rare, DMTs may cause serious side effects. Not everyone who takes these medications experiences serious side effects. Individuals should discuss all safety concerns with their doctor prior to beginning treatment with a DMT.^4-19

• Alemtuzumab (Lemtrada®) – Infusion-associated reactions and severe allergic reactions, rare viral disease (progressive multifocal leukoencephalopathy), development of secondary or new autoimmunity, including thyroid autoimmune disorders, increased risk of certain cancers, infections (including opportunistic such as herpes virus, human papilloma virus, fungal infections, listeria, and nocardiosis)
• Cladribine (Mavenclad®) – Increased risk of infections and malignancies, worsening of chronic infections such as HIV, hepatitis or TB, fetal harm.
• Dimethyl fumarate (Tecfidera®) – Severe allergic reaction, lowered white blood cell counts, liver injury, rare viral disease (progressive multifocal leukoencephalopathy), swelling (angioedema) in the face, tongue, throat, abdomen, hands, or feet
• Diroximel fumarate (Vumerity®) – Allergic reactions including welts and hives, PML (progressive multifocal leukoencephalopathy – a rare brain infection, shingles, decrease in white blood cell count, severe liver problems
• Fingolimod (Gilenya®) – Change in heart rhythm that may cause sudden death, increased risk of infections, rare viral disease (progressive multifocal leukoencephalopathy), increased fluid in the retina (macular edema), posterior reversible encephalopathy syndrome, respiratory effects, liver injury, risk of causing birth defects, increased blood pressure, basal cell carcinoma
• Glatiramer acetate ( Copaxone®) – Post-injection reaction (rapid heartbeat, anxiety, throat constriction)
• Interferon beta-1a (Avonex®) – Liver damage, severe allergic reaction, depression (and suicidal thoughts), congestive heart failure, seizures, autoimmune disorders, leukopenia thrombotic microangiopathy, decreased peripheral blood counts
• Interferon beta-1a (Rebif®) – Liver damage, severe allergic reaction, depression (and suicidal thoughts), congestive heart failure, seizures, autoimmune disorders, leukopenia thrombotic microangiopathy, decreased peripheral blood counts
• Interferon beta-1b (Betaseron®) – Liver damage, severe allergic reaction, depression (and suicidal thoughts), congestive heart failure, seizures, autoimmune disorders, leukopenia thrombotic microangiopathy, decreased peripheral blood counts
• Interferon beta-1b (Extavia®) – Liver damage, severe allergic reaction, depression (and suicidal thoughts), congestive heart failure, seizures, autoimmune disorders, leukopenia thrombotic microangiopathy, decreased peripheral blood counts
• Mitoxantrone (Novantrone®) – Congestive heart failure (can result in death) may occur either during or months to years after termination of therapy. Secondary acute myeloid leukemia, infection, lowered white blood cell counts, depression, vomiting, kidney failure
• Natalizumab (Tysabri®) – Rare viral disease (progressive multifocal leukoencephalopathy), severe allergic reactions, suppression of the immune system, increased risk of infections (including herpes simplex virus, meningitis), and liver injury
• Ocrelizumab (Ocrevus®) – Increased risk of infections, increased risk of certain cancers
• Ozanimod (Zeposia®) – Change in heart rhythm, increased risk of infections, liver damage, respiratory effects, macular edema, increased blood pressure
• Peginterferon beta-1a (Plegridy®) – Liver damage, severe allergic reaction, depression (and suicidal thoughts), congestive heart failure, seizures, autoimmune disorders, leukopenia thrombotic microangiopathy, decreased peripheral blood counts
• Siponimod (Mayzent®) – Macular edema, increased risk of infections, decrease in heart rate
• Teriflunomide (Aubagio®) – Liver injury, risk of causing birth defects, bone marrow effects, suppression of the immune system, increased risk of infections, peripheral neuropathy, skin conditions, increased blood pressure, respiratory effects, pancreatitis, lowered white blood cell counts

 

Advances in MS Treatment

  New treatments for MS are coming online all the time. Some are approved by the FDA, while others are still in clinical trials. See how they may help treat your symptoms.

 

Drugs May Help Rebuild Myelin

Two drugs, metformin (Fortamet, Glucophage, Glumetza, Riomet) and clemastine (Dayhist, Tavist), may help rebuild your myelin. Usually, metformin treats diabetes and clemastine helps with hay fever. Researchers found metformin can help myelin-making cells repair it better. Experts found clemastine helped with the speed of messages from your eye to your brain. Animal studies showed metformin can improve the effect of clemastine.

More research is needed about the effects on humans.

Pioglitazone May Prevent Myelin Damage

Experts are doing clinical trials with pioglitazone (Actos), a diabetes medication, in people with progressive MS. They want to see whether the drug can target immune system attacks on myelin. Pioglitazone may be a useful therapy to protect nerve fibers from more damage and even repair damage to myelin.

BTK Blockers May Lessen Nerve Damage

Bruton’s tyrosine kinase (BTK) plays a role in the survival of B cells, white blood cells that make antibodies. Some B cells are linked to MS relapses and progression because they attack myelin. BTK inhibitors (BTKis) target B cells that can do damage while leaving useful B cells alone. BTKis were first used to treat cancer. Now scientists are studying some BTKis – evobrutinib, fenebrutinib, orelabrutinib, and tolebrutinib – in clinical trials to find out how effective they are against MS.

ATA188 Targets EBV, May Help MS 

This therapy targets Epstein-Barr virus (EBV), which is believed to play a role in how likely you are to get MS. ATA188 involves T cells (white blood cells in the immune system) that target and kill cells infected with EBV. Experts are studying the proper dosages, safety, and success of this intravenous (IV) infusion and how it can help treat progressive MS. 

Stem Cell Therapy for Harmful Cells

This treatment uses or targets stem cells, which are cells that can turn into different types of specific cells all over your body. They can help your body repair itself. One form of stem cell therapy is hematopoietic stem cell transplantation (aHSCT). Experts use this to reset your immune system through chemotherapy. If you have MS, this will get rid of harmful cells that cause damage and swap them with healthy immune cells. 

DMTs That Can Change the Course of MS

Disease-modifying therapies (DMTs) can help control your MS symptoms. The FDA has approved different types of medication to treat and manage MS:

• Ocrelizumab (Ocrevus), ofatumumab (Kesimpta), and ublituximab-xiiy (Briumvi) target CD20, a protein on the surface of B cells. These B cells are white blood cells that have been shown to play a role in MS.
• Diroximel fumarate (Vumerity) lessens inflammation and stops nerve damage that may cause MS symptoms.
• Fingolimod (Gilenya) reduces the MS relapse rate in adults and children. It’s the first FDA-approved MS drug for kids.

Other DMTs That Can Change the Course of MS

• Ozanimod (Zeposia) can help with clinically isolated syndrome, relapsing-remitting MS, and active secondary progressive MS.
• Ponesimod (Ponvory) can lower the chance of MS symptoms coming back by more than 30%.
• Cladribine (Mavenclad) and siponimod (Mayzent) are other treatments that can lower your relapse rate if you have MS. They stop certain cells of the immune system from causing nerve damage.

Cladribine for Other Forms of MS

As mentioned, this drug already helps people with relapsing-remitting MS. The first trial of its kind is studying whether cladribine can help more advanced progressive MS. Experts are hopeful because it’s one of the few DMTs that can get inside your brain and spinal cord. That's why it’s so helpful for relapsing MS.

Cholesterol Drugs May Help With MS

Simvastatin (Flolipid, Zocor) is a statin doctors prescribe to treat high cholesterol. It may also help slow down secondary progressive MS. Some studies show that higher cholesterol levels are linked to worsened MS. Because of this, experts thought simvastatin might slow down MS progression if it lowers your cholesterol. But a more recent study found that the drug directly slows down the progression of MS, even if it doesn’t help your cholesterol levels.

 

From: WebMD