Medications for multiple sclerosis (MS) include a wide variety of drugs to modify the course of the disease, treat relapses, or help manage symptoms.
MS is a condition that affects the nervous system. The course of the condition is different for each individual, as are the symptoms they will experience.
This article discusses the different types of disease-modifying therapies (DMTs) for MS and how they work.
It also provides details on drugs to treat individual symptoms of MS, dosage, and side effects.
MS results from damage to the coating of nerve fibers in the brain, spinal cord, and optic nerve.
DMTs are not a cure for MS, but they may help slow the progression of the disease and reduce the number and severity of relapses, according to the Multiple Sclerosis Association of America (MSAA).
In many cases, researchers do not know exactly how a particular DMT works. In general, the drugs may act to calm the immune system and lessen the attack on nerve cells.
Injectable therapies
A person with MS can inject these medications themselves or ask a caregiver to do it for them.
It is important to note that the Food and Drug Administration (FDA) has not approved injectable DMTs for use during pregnancy or lactation.
There are three types of injectable DMTs:
Beta interferon drugs
Beta interferon drugs help regulate the immune cells.
The following information is from the National Multiple Sclerosis Society (NMSS):
| Drug | Administration | Dose |
|---|---|---|
| Avonex | injected into a muscle, or intramuscularly, with a pre-filled syringe or auto-injector | 30 micrograms (mcg) once per week |
| Betaseron | injected under the skin, or subcutaneously | 0.25 milligrams (mg) every other day |
| Extavia | injected under the skin using a syringe or auto-injector | 0.25 mg every other day |
| Rebif | injected under the skin using a pre-filled syringe or auto-injector | 22 mcg or 44 mcg three times per week |
| Plegridy | injected under the skin or into a muscle | 125 mcg every 14 days |
Common side effects include:
- chills
- fever
- muscle aches
- headache
- fatigue
- pain or inflammation at the injection site
More severe side effects may include:
- depression
- suicidal thoughts
- liver conditions
- heart conditions, such as heart failure
- low counts of red and white blood cells or platelets
- damage to small blood vessels, red blood cells, and platelets
Glatiramer acetate
These drugs help change the balance of the immune cells and include:
| Drug | Administration | Dose |
|---|---|---|
| Glatopa | injected under the skin using a pre-filled syringe | 20 milligrams per milliliter (mg/ml) per day or 40 mg/ml three times per week |
| Copaxone | injected under the skin using a pre-filled syringe | 20 mg/ml per day or 40 mg/ml three times per week |
They cause the following side effects:
- pain at the injection site
- rash
- shortness of breath
- chest pain
More severe side effects include damage to fatty tissue under the skin and liver problems.
B cell depletion therapy
B cell depleting therapies are among the most effective treatments for MS. These drugs target B cells that cause nerve damage in the brain and spinal cord.
| Medication | Brand name | Administration | Dose |
|---|---|---|---|
| Ocrevus | intravenous infusion directly into the bloodstream. | 300 mg twice, 2 weeks apart, then 600 mg once per 6 month | |
| Ofatumumab | Kesimpta | injection under the skin using a pre-filled syringe | 20 mg once a week for 3 weeks, 1 week off, then once per month |
Side effects of B cell depletion therapy include:
- nausea
- rash
- itching
- hives
- headache
Oral therapies
A person with MS can take the following oral therapies:
| Medication | Brand name | Dose | Common side effects |
|---|---|---|---|
| teriflunomide | Aubagio | a 7-mg or 14-mg pill once per day | headache nausea diarrhea abnormal liver tests thinning hair |
| monomethyl fumarate | Bafiertam | 95 mg twice daily for 1 week, followed by 190 mg twice per day | nausea diarrhea abdominal pain flushed skin |
| dimethyl fumarate | Tecfidera | 120 mg twice daily for 1 week, followed by a 240-mg capsule twice per day | nausea diarrhea abdominal pain flushed skin |
| diroximel fumarate | Vumerity | 231 mg twice daily for 1 week, followed by 2 231-mg pills twice per day | nausea diarrhea abdominal pain flushed skin |
| cladribine | Mavenclad | 2 treatment courses of 4–5 days per year | headache respiratory infection reduced white blood cell count |
| siponimod | Mayzent | 1 mg or 2 mg per day | high blood pressure headache abnormal liver tests |
| fingolimod | Gilenya | a 0.5-mg capsule once per day for those weighing more than 40 kilograms (kg) 0.25 mg for those who weigh 40 kg or less | headache pain in the back, abdomen, or extremities diarrhea cough flu sinusitis abnormal liver tests |
| ozanimod | Zeposia | 0.23 mg for 4 days, followed by 0.46 mg for 5–7 days, followed by 0.92 mg once per day | high blood pressure back pain upper respiratory infections abnormal liver tests blood pressure drop upon standing frequent, painful urination |
| ponesimod | Ponvory | increasing dose from 2—20 mg per day over 14 days, then 20 mg per day | infection high blood pressure low white blood cell count herpes |
Infusion therapies
In addition to oral and self-injected drugs, DMTs include medications that a person receives through an intravenous (IV) infusion.
A healthcare professional administers these through a needle placed into a person’s vein.
Infusion therapies include:
- Natalizumab (Tysabri): A healthcare professional will administer this once per month. Experts associate the use of the drug with an increased chance of progressive multifocal leukoencephalopathy, a potentially fatal brain infection.
- Ocrelizumab (Ocrevus): A healthcare professional will administer this every 6 months. The FDA has approved the therapy for primary progressive and relapsing forms of MS. The drug may increase the risk of infections and cancer.
- Alemtuzumab (Lemtrada): A healthcare professional will administer this for 5 days in a row, followed by 3 days 1 year later. Therapy with this drug may increase the risk of autoimmune conditions.
- Mitoxantrone (Novantrone): A healthcare professional will administer this four times per year. Side effects may include heart damage and certain blood cancers.
Most people with MS initially have relapses, which are a worsening of symptoms or the appearance of new symptoms for several days up to a few months. The symptoms then subside.
Learn more about MS exacerbations here.
If a relapse is severe enough, a healthcare professional may recommend treatment with an IV infusion of certain medications for several days.
Medications for relapses include corticosteroids, a type of steroid that helps decrease inflammation in the central nervous system.
These include:
- methylprednisolone (SoluMedrol) via IV
- dexamethasone (Decadron) via IV
- prednisone taken orally to help taper off IV treatment slowly
Side effects of corticosteroid treatment may include:
- headache
- increased appetite
- indigestion
- high blood pressure
- heart palpitations
- metallic taste in the mouth
- trouble sleeping
- mood swings
- swollen ankles
An alternative to corticosteroids is Acthar gel. A person takes this drug through an injection under the skin or into a muscle once per day for several weeks.
Acthar contains a form of adrenocorticotropin, which tells the body to make more steroids.
Side effects of Acthar gel are similar to those of corticosteroids.
MS can cause a person to experience symptoms such as an overactive bladder, urinary incontinence, or constipation.
Bladder conditions
According to MSAA, MS can cause a muscle in the bladder wall, called the detrusor muscle, to contract. This reduces the amount of urine the bladder can hold, producing symptoms such as a frequent need to urinate.
MS can also interfere with nerve signals to the urinary sphincter. As a result, a person may have trouble emptying their bladder.
Darifenacin (Enablex) is a drug that relaxes the bladder muscles to help relieve an overactive bladder.
The recommended starting dose of Enablex extended-release tablets is 7.5 mg per day, which a person may increase to 15 mg per day.
Side effects include:
- headache
- upper abdomen discomfort
- nausea
- constipation
- dry mouth
- urinary tract infection
Other drugs that may help relieve an overactive bladder in MS include:
- tolterodine (Detrol)
- oxybutynin (Ditropan)
- solifenacin succinate (Vesicare)
- mirabegron (Myrbetriq)
Another option is tamsulosin (Flomax). This drug may relax the muscles in the prostate and bladder to improve the flow of urine. The dose is typically 0.4 mg per day.
Healthcare professionals predominantly prescribe Flomax for males with MS.
Common side effects include:
- headache
- dizziness
- runny or stuffy nose
- diarrhea
- insomnia
- decreased sex drive
Bowel dysfunction
MS may disrupt the nerve signals to muscles that help empty the bowels.
Almost 70% of people with MS experience bowel problems, which in most cases is constipation, according to MSAA.
Drinking more fluids, eating more fiber, and exercising regularly often help. In addition, a person can try over-the-counter medications that may relieve constipation. These include:
- stool softeners, such as docusate
- fiber supplements
- stimulant laxatives, such as magnesium hydroxide
People with MS may feel a wide range of emotions after receiving a diagnosis. Additionally, damage to nerve fibers in the brain may also cause emotional changes, according to the NMSS.
Emotional changes
About 10% of people with MS will experience pseudobulbar affect (PBA), in which an individual has bouts of uncontrolled laughter or crying that are not related to how they are feeling.
Nuedexta is a form of to treat PBA. A person typically starts by taking 1 capsule per day for 7 days, followed by 1 capsule every 12 hours.
Possible side effects include:
- dizziness
- cough
- diarrhea
- vomiting
- weakness
- swelling in the legs
- flatulence
- influenza
- urinary tract infection
Depression
Depression is common in people with MS.
The latter include:
- citalopram (Celexa)
- paroxetine (Paxil)
- fluoxetine (Prozac)
- sertraline (Zoloft)
Among possible side effects are:
- headaches
- anxiety
- indigestion
- constipation
- diarrhea
- loss of appetite
- dry mouth
- difficulty sleeping
- reduced sex drive
MS can cause movement and coordination difficulties.
Tremors
There are no specific medications for tremors. However, some medications can have secondary effects that may help reduce tremors.
These include:
- hydroxyzine (Atarax, Vistaril), an antihistamine that can help reduce stress-induced tremors
- clonazepam (Klonopin) or buspirone (Buspar), which are antianxiety medications that have a sedative effect
- propranolol (Inderal), a beta-blocker
- ondansetron (Zofran), a type of antinausea medication
- primidone (Mysoline), an anti-epileptic medication
- acetazolamide (Diamox), a diuretic
- onabotulinumtoxinA (Botox), a neurotoxin
- isoniazid (Laniazid), an antibiotic
Spasticity
Spasticity occurs when a person has muscle stiffness or spasms. It is a common symptom of MS.
The FDA approved a muscle relaxant called baclofen (Lioresal) for treating spasticity in MS.
The maximum dose is 20 mg four times per day.
Common side effects include drowsiness, dizziness, and weakness.
Many people with MS experience difficulty walking and maintaining their balance. Physical therapy and the use of a cane or walker may help.
In addition, doctors may prescribe dalfampridine (Ampyra) to help people with MS walk faster. However, this drug is not suitable for people with a history of seizures nor those with moderate to severe kidney impairment.
The drug blocks the flow of potassium across the surface of nerve cells, and this may improve their ability to send signals to other cells.
The maximum dose is two 10-mg tablets each day.
Side effects include:
- urinary tract infection
- trouble sleeping
- dizziness
- headache
- nausea
Medications known as nonsteroidal anti-inflammatory drugs, such as ibuprofen, may help reduce aches and pains.
People with MS may also experience neuropathic pain that results from irritation of or damage to the nerves. According to the NMSS, the damaged nerves may produce stabbing, burning, or squeezing sensations.
A doctor might prescribe certain drugs off-label for treating neuropathic pain. These include medications that the FDA approved for treating seizures or depression.
Some of them are FDA-approved for treating certain types of nerve pain:
| Drug | Brand name | Type | Side effects |
|---|---|---|---|
| duloxetine | Cymbalta | antidepressant | nausea diarrhea constipation dizziness insomnia fatigue |
| gabapentin | Neurontin | anti-seizure | dizziness drowsiness peripheral edema, or swelling |
| carbamazepine | Tegretol | anti-seizure | dizziness drowsiness difficulty walking nausea vomiting |
A person should consult a healthcare professional about the suitable dosages to treat MS-related pain.
People with MS often experience physical or mental fatigue. Mild to moderate exercise each day
Medications to help reduce fatigue include:
- Amantadine: Common side effects are nausea, insomnia, and dizziness. Less frequently, side effects may include anxiety, dry mouth, and constipation.
- Modafinil: Common side effects include headache, insomnia, dizziness, diarrhea, rhinitis, and back pain.
- Methylphenidate: Common side effects include appetite loss, difficulty sleeping, mood swings, headaches, and an increase in heart rate and blood pressure.
To treat fatigue, doctors may also prescribe amphetamine stimulants, such as Adderall. However, as this is not their intended use, they are known as off-label prescriptions.
A person should speak with a healthcare professional about the dosages to help treat MS-related fatigue.
Damage to the myelin, a fatty substance that covers the nerve fibers, can lead to a variety of visual and eyesight problems.
Typically, these will resolve without treatment. However, severe symptoms may warrant the use of IV steroid medications.
People with MS can use hydroxyzine (Vistaril) to treat itching or burning sensations. Hydroxyzine is an antihistamine.
The typical dosage for MS-related itching is 25 mg for adults up to four times per day, as needed.
Examples of the side effects include headache, drowsiness, skin rash, and dry mouth.
A person with MS can take meclizine (Antivert) to treat dizziness.
A person should take 25–100 mg daily in divided doses.
Side effects may include a severe allergic reaction known as anaphylaxis, drowsiness, dry mouth, headache, fatigue, vomiting, or blurred vision.
MS can lead to:
- libido loss
- difficulty reaching an orgasm
- reduced sensation in the penis or vaginal and clitoral area
- vaginal dryness
- difficulty achieving and maintaining an erection
If a person is having difficulty maintaining an erection, there are oral and injectable medications available.
Learn more about the treatment options for erectile dysfunction here.
A person experiencing vaginal dryness can use water-soluble personal lubricants. It is important to note that petroleum jelly is not a suitable personal lubricant, as it can lead to an infection.
Learn more about the treatment options for vaginal dryness here.
The cost of DMTs can be high. A person’s health insurance may cover some of the costs of a DMT treatment.
Learn more about Medicare and MS drugs here.
Additionally, manufacturers of DMTs offer patient assistance programs.
A person can also ask the doctor’s office for a reduced rate or payment plan to help with the costs of DMTs.
Below are some frequently asked questions about MS medication.
What are first line treatments for MS?
Disease-modifying therapies (DMTs) are the
Do all people with MS take medication?
Not everyone with MS takes medication. The best treatment plan for an individual with MS may depend on their symptoms and circumstance.
People should speak with their healthcare team to learn all of their options, including the benefits and risks of different treatments.
How fast does MS progress without medication?
MS may progress faster if a person does not receive treatment. However, progression can vary from person to person. MS is an unpredictable condition, and it is impossible to accurately predict progression rate.
Can a person with MS live without medication?
A person with MS can choose to stop or forego treatment. However, there is a higher risk that their condition will relapse or progress faster than if they were receiving active treatment.
According to the NMSS, the best way for people with MS to manage the disease is to adopt a healthy lifestyle, treat the symptoms, and use DMTs.
Medications can play an important role in helping individuals with MS improve their quality of life.
People with MS should work closely with their doctors to determine the most appropriate treatment.