MS disease modifying Rx

Posted On July 24, 2021

Who should be treated

  • Clinically definite relapsing remitting MSD (RRMS)
  • Some patients with
    • Clinically isolated syndrome (CIS)
    • secondary progressive MS (SPMS)
  • Choice of therapy depends on: age, severity of disease, patient choice, risk of side effects

Highest efficacy

  • High to low efficacy is based on limited randomized trials
  • All drugs in the highest efficacy group have major severe side effects, restrictions and monitoring requirements and should be used ONLY by experienced clinicians
  • Consider only for severe disease or failed other therapy
  • Monoclonal antibodies:
    • Natalizumab (Tysabri)
      • 300 mg iv over 1 hour monthly
    • Ocrelizumab (Ocrevus)
      • slowly increasing rate of infusion
      • 300 mg iv on day 1, 300 mg 2 weeks later, then 600 mg every 6 months
    • Ofatumumab (Arzerra, Kesimpta)
      • Kesimpta: 20 mg sq weekly x3, then monthly
    • Alemtuzumab (Lemtrada)
      • Lemtrada: IV: 12 mg daily for 5 days, followed 12 months later by 12 mg daily for 3 days.
      • Subsequent treatment: 12 mg daily for 3 days may be administered if necessary
      • courses should be administered no earlier than 12 months after the last dose of the prior treatment cycle.
    • possibly Cladribine (Mavenclad)
      • immunosuppressive purine antimetabolite agent that targets lymphocyte subtypes
      • 3.5 mg/kg oral dose divided into 2 doses yearly treatment
      • meaning 1.75 mg/kg dose given over 5 days, repeat after 4 weeks

Intermediate efficacy

  • S1P receptor modulator : fingolimod (Gilenya)
    • first dose: 6 hour monitoring is required with capability to manage bradycardia
    • 0.5 mg oral daily
    • significant drug interactions
  • ** Fumarates: dimethyl fumarate (Tecfidera)
    • consider this if convenience is the main concern
    • 120 mg po bid for 7 days, then 240 mg bid
    • generic available: cost $250 for 60 cap

Lower efficacy

  • Teriflunomide (Aubagio)
    • 7 or 14 mg oral qd
    • may cause life threatening liver injury
  • Interferons
    • ** Avonex: Interferon beta-1a. 30 mcg intramuscular injection weekly
    • Betaseron: Interferon beta-1b. 0.25 mg (1 mL) subcutaneously every other day
    • Rebif: Interferon beta-1a 22 or 44 mcg subcutaneously three times a week
    • Plegridy: Subcutaneous pegylated interferon beta-1a, 125 mg once every two weeks
  • ** Glatiramer (Copaxone)
    • consider this if safety is the main concern
    • 20 mg sq daily or
    • 40 mg sq 3 times a week

References