MS disease modifying treatment

Posted On February 14, 2020

Relapsing remitting multiple sclerosis (RRMS) initial therapy

Very active disease:
- Natalizumab (Tysabri) 300 mg iv q 4 w
  - Natalizumab: Risk of PML, 4 in 1000.
  - check anti JC virus Ab before and at 1 year, then q 6 months
- or Ocrelizumab (Ocrevus):
  - 300 mg iv, then 300 mg iv in 2 weeks, then 600 mg iv q 6 months
  - infusion reaction common
  - premedicate with Methylprednisolone 100 mg iv, and diphenhydramine
- more effective than interferon beta-1a
If Safety is main concern:
- glatiramer (copaxone), 20 mg sq qd or 40 mg sq tiw
- Avonex: Interferon beta 1a 30 mcg im weekly
- Rebif: interferon beta 1a sq: 8.8 mcg tiw x2 weeks, then 22 mcg tiw x 2weeks, then 44 mcg tiw
For Convenience: oral therapy
- Oral dimethyl fumarate delayed-release capsules (Tecifedera) , 120 mg twice daily for one week, then 240 mg twice daily
If refractory to initial DMT. switch to another first-line disease-modifying agent

Teriflunomide (Aubagio): risk of liver problem, needs close LFT monitoring
Fingolimod (Gilenya): 0.5 mg qd, avoid in patients with heart disease, Diabetes, child bearing age
- Needs CBC, LFT, EKG
- Ophthalmologic examination
- Varicella serology and varicella zoster virus vaccination if antibody negative for those without a history of chicken pox or prior vaccination; fingolimod should not be started until one month after vaccination
- skin examination at baseline to screen for evidence of precancerous skin lesions.