A Guide to Multiple Sclerosis Medications

Medications are the mainstay of treatment for multiple sclerosis (MS). Many of them are used to block the immune system's attack on the nerves and slow or prevent progression and relapses (flare-ups) of the disease. Others are used to manage resulting symptoms like pain, depression, and muscle stiffness.

There are several types of medications that can be used to treat MS, including chemotherapy drugs, anti-inflammatories, immunosuppressive drugs, and steroids. In some cases, medications for MS are categorized based on how they are administered, what they do, and what symptoms they manage.

Read on to discover the various forms of medications for MS and how they help people with the disease.

Disease-Modifying Therapies (DMTs)

Several kinds of disease-modifying therapies (DMTs) may change the course of MS. Depending on how effective the medications are for any given person, the length of treatment varies, but it can range from a few months to years.

How well a person tolerates a medication's side effects and how well the medication manages their symptoms are factors that doctors use to determine whether or not a person will stay on a specific treatment or switch to a new type of medication.

A doctor will monitor to see if any new lesions develop and in which are areas of the brain the nerve cells have been stripped of myelin. If new lesions do develop, a doctor may switch to a new DMT.

Injections and Infusions

There are several injectable medications that have been approved by the Food and Drug Administration (FDA) to treat MS.

Interferon Beta Injectable Drugs

Interferon beta injectable drugs were the first DMTs approved for MS treatment. The injections help change the course of active relapsing-remitting MS and secondary progressive MS. If a person has relapsed or presents with new lesions caused by damage to the nerves, they are a good candidate for interferon beta injectable drugs.

Interferon beta injectable drugs can include:

• Interferon beta 1a (Rebif, Avonex)
• Interferon beta 1b (Extavia, Betaseron)
• Peginterferon beta 1a (Plegridy)

These medications hinder the ability of white blood cells, which are immune cells, from getting into the brain and spinal cord to cause more damage to the nerves. Since it is thought that MS is driven by autoimmunity (meaning the immune system begins to attack itself), blocking the action of these immune cells can slow the progression of the damage that is caused by MS.

Interferon beta injectable drugs are considered to be safe for many people with MS. However, they do come with some side effects, including:

• Flu-like symptoms
• Headaches
• Chills
• Pain or a rash at the injection site
• Fever
• Muscle aches and pains

Natalizumab (Tysabri, Tyruko)

Natalizumab is a type of antibody, a specialized protein designed to identify foreign invaders in the body. This medication blocks a specific type of immune cell (T lymphocytes) from entering the brain and spinal cord.

This medication is typically used to treat active disease in people with secondary progressive or relapsing-remitting MS, but it is sometimes given to people with CIS.

Tysabri and Tyruko are two FDA approved medications containing natalizumab, and Tyruko is a biosimilar to Tysabri. Natalizumab is infused every 28 days and includes a boxed warning due to the increased risk of developing progressive multifocal leukoencephalopathy (PML).

Side effects of natalizumab can include:

• Headache
• Urinary tract infection
• Lung infection
• Muscle aches and pains
• Abdominal pain
• Vaginal infection (vaginitis)
• Depression
• Diarrhea
• Nausea
• Rash
• Joint stiffness
• Fatigue 

Glatiramer Acetate (Glatopa, Copaxone)

Glatiramer acetate is a synthetically made substance that is meant to resemble a specific protein in myelin. The medication works by tricking the immune cells into attacking it instead of the body's myelin. It is typically used to treat relapsing-remitting MS or CIS.

You will inject this medication yourself either once every day or once three days per week. It's important to follow your provider's directions for taking this medication to make sure you are giving yourself the correct dose.

The most common side effects of glatiramer acetate are a rash or pain at the injection site.

Alemtuzumab (Lemtrada)

Alemtuzumab is not a first-line therapy for MS. It is intended for people who have tried more than two other MS medications without relief from their symptoms or slowing of the progression of the disease.

The medication works by reducing the number of immune cells (B and T lymphocytes) in the body, which can help reduce inflammation and decrease damage to the nerve cells.

Alemtuzumab is given as an infusion, similar to glatiramer acetate. However, the alemtuzumab infusion takes four hours.

The treatment regimen for alemtuzumab is:

• First course: Once per day for five days in a row
• Second course: Once per day for three days in a row
• 12 months with no infusions
• Subsequent courses: Once per day for three days in a row as needed, at least 12 months after the last dose of any previous courses

The side effects of this drug can include:

• Fever
• Chills
• Dizziness
• Shortness of breath
• Nausea and/or vomiting
• Mild rash or itching
• Flushing

Mitoxantrone Hydrochloride

Mitoxantrone hydrochloride was originally approved as a chemotherapy treatment, but it is also used to treat MS. The medication works by suppressing the action of the immune system cells that attack and damage myelin. Typically, relapsing-remitting and secondary progressive MS are treated using mitoxantrone hydrochloride.

The medication is administered through an IV infusion once every three months by a healthcare provider. The infusion lasts roughly five to 15 minutes.

The most common side effects of mitoxantrone hydrochloride include:

• Changes in or lack of menstrual periods during treatment
• Nausea
• Thinning hair
• Urine that is blue-green in color for roughly 24 hours after the infusion was given
• Upper airway and urinary tract infections
• Headaches
• Constipation
• Vomiting
• Diarrhea

Ofatumumab (Kesimpta)

Ofatumumab is the newest treatment for MS. It can be used to treat CIS, relapsing-remitting MS, and secondary progressive MS.

The medication works by singling out certain harmful immune cells (B lymphocytes) and reducing how many there are in the body. This leads to less damage because there are fewer B cells targeting the myelin in the brain and spinal cord.

This injectable medication is administered under the skin (subcutaneously) once per week for three weeks, followed by a one-week break, and then once a month after that. The first injection should be done under the guidance of a healthcare professional. After that, you will inject the medication yourself.

Some common side effects of ofatumumab include:

• Redness, pain, itching, or swelling at the injection site
• Fever
• Headaches
• Muscle aches and pains
• Chills
• Fatigue
• Chest infections
• Colds and head colds
• Cold sores
• Urinary tract infections
• A decrease in the molecules that help protect the body against infection (antibodies)

Ocrelizumab (Ocrevus)

Ocrelizumab is an infusion medication that treats CIS, relapsing-remitting MS, and primary progressive MS. It works similarly to ofatumumab, as it reduces the number of B lymphocytes in the body, thereby decreasing the number of cells that are available to damage the myelin.

The medication is given as an infusion. Two separate infusions will be given, with a two-week break between them, with regular infusions being given once every six months. Each infusion will take between three and four hours.

Side effects of ocrelizumab can include:

• Headaches
• Rash
• Fever
• Nausea
• Cold sores
• Cough

Oral Medications

There are also oral medications that have been approved by the FDA to treat MS, including:  

• Dimethyl fumarate (Tecfidera): Taken in oral capsules twice per day, this medication is thought to modulate the immune system to help lessen the damage to the brain and spinal cord nerves. 
• Cladribine (Mavenclad): This compound drug suppresses the action of the immune system by reducing the number of B and T lymphocytes in the body, which prevents further damage to nerve cells.
• Diroximel fumarate (Vumerity): This drug is taken twice per day. After it is broken down in the body, it converts into monomethyl fumarate and has the same immune-modulating action as dimethyl fumarate.  
• Fingolimod (Gilenya): This drug works by preventing white blood cells from getting into the central nervous system by trapping them in the bean-shaped structures involved in immune function (lymph nodes).
• Monomethyl fumarate (Bafiertam): Taken twice per day, this oral medication works similarly to dimethyl fumarate and diroximel fumarate by modulating the immune response and reducing inflammation.
• Ozanimod (Zeposia): This drug traps white blood cells in the lymph nodes, which keeps them from passing into the central nervous system where they can cause further damage.
• Siponimod (Mayzent): Similar to ozanimod, siponimod retains white blood cells in the lymph nodes to ensure they do not get into the central nervous system. It also reduces inflammation.

Medications for MS Symptoms

Some MS medications are designed to treat or manage MS based on specific symptoms or other conditions that arise.

Bladder Symptoms

Bladder symptoms affect up to 80% of people with MS. Medications that treat or manage bladder dysfunction tend to work by relaxing bladder muscles to prevent the over-contraction of the muscles. They can also reduce muscle spasms, block connections between the nerves and muscles in the bladder, and help to encourage the flow of urine.

Medications that can treat bladder symptoms in MS include:

• Darifenacin (Enablex): This medication works by relaxing the bladder muscles to help prevent contractions that lead to the inability to control the bladder (incontinence). It also helps prevent the urgent and frequent need to urinate.
• Desmopressin (DDVAP nasal spray): Given as a nasal spray, this hormone affects the kidneys. It helps to control the frequent need to urinate.
• Imipramine (Tofranil): This antidepressant can help with urinary frequency and incontinence.
• Mirabegron (Myrbetriq): This medication treats an overactive bladder by relaxing the muscles in the urinary tract and reducing bladder spasms.
• Onabotulinumtoxin A (Botox): This neurotoxin provides relief by blocking connections that can make muscles tight and cause spasms.
• Oxybutynin (Ditropan, Ditropan XL, Oxytrol): This medication works by decreasing the number of muscle spasms that occur in the bladder, thus relieving urinary symptoms that are caused by the spasms.
• Prazosin (Minipress): This medication is typically used to treat high blood pressure, but for people with MS, it can help to promote the flow of urine.
• Solifenacin (VESIcare): This drug is designed to treat overactive bladder.
• Tamsulosin (Flomax): By relaxing the muscles in the bladder and the prostate, this medication can help to promote urine flow in people with MS.
• Tolterodine (Detrol): This medication is in the same class as solifenacin and helps to relax bladder muscles and prevent an overactive bladder.

Emotional Changes

Some people with MS may experience abrupt emotional symptoms that might not be appropriate for the situation they are in—for example, laughing or crying uncontrollably. Dextromethorphan + quinidine (Nuedexta) is a combinational therapy that helps to treat these episodes.

Bowel Dysfunction

Roughly 39% to 73% of people with MS experience bowel dysfunction. One of the most common bowel symptoms that people with MS experience is constipation.

There are different types of medications that can be used to treat constipation, including laxatives, stool softeners, and bulking agents.

Some laxatives that can be used for constipation caused by MS include:

• Bisacodyl (Dulcolax)
• Fleet enema
• Magnesium hydroxide (Phillips’ Milk of Magnesia)

Stool softeners for constipation that is caused by MS include:

• Docusate (Colace)
• Glycerin suppositories
• Mineral oil

The bulking agent that is most often used to treat MS-driven constipation is psyllium fiber (Metamucil). 

Fatigue

Over 80% of people with MS experience fatigue. Medications designed to treat fatigue include:

• Dextroamphetamine and amphetamine (Adderall): This medication stimulates the central nervous system to improve mental alertness.
• Amantadine (Gocovri, off-label): This antiviral medication is used off-label to treat MS fatigue, which means that it was not developed for this purpose. The reason for its action against fatigue is not clear; however, it helps some people with MS feel more alert.  
• Methylphenidate (Ritalin): Another drug used off-label for MS fatigue, this medication helps to stimulate the central nervous system to encourage mental alertness.
• Modafinil (Provigil): This medication is designed to encourage a feeling of wakefulness. It was made to help treat obstructive sleep apnea and shift work sleep disorder but is used off-label to treat MS fatigue.
• Fluoxetine (Prozac, off-label): This medication is also used off-label for MS and can help improve fatigue. It is an antidepressant that is typically used to treat depression, obsessive-compulsive disorder, and panic attacks.

Pain and Dysesthesia

Up to 75% of people with MS experience some form of chronic pain or abnormal sensations (dysesthesia). To help treat these feelings, medications include:

• Amitriptyline: This antidepressant helps treat pain and abnormal sensations in the arms and legs that can develop after certain pathways are damaged in the course of MS.
• Clonazepam (Klonopin): Klonopin is typically used to treat seizures and panic attacks, but it can also be used to manage pain in people with MS when they have not gotten relief from other treatments.
• Gabapentin (Neurontin): This anti-seizure medication can help control pain that is caused by damage to the nerve cells in the brain and spinal cord.
• Nortriptyline (Pamelor): Another antidepressant that is used to treat pain symptoms in MS, this medication is thought to help with pain in the arms and legs.
• Phenytoin (Dilantin): This medication is typically used to treat seizures, but it can also help manage pain in people with MS.

Itching

Itching is a symptom that many people with MS experience. They also can have abnormal sensations such as pins and needles or burning, stabbing, or tearing pains.

The medication that is most often used to treat itching in people with MS is hydroxyzine (Vistaril), an antihistamine that is typically used to prevent allergy symptoms.

Depression

Nearly 50% of people with MS develop depression. The most common antidepressant medications given to people with MS are selective serotonin reuptake inhibitors (SSRIs).

SSRIs block nerves from absorbing the neurotransmitter serotonin. When too much serotonin is absorbed by nerve cells, there is not enough left to continue sending messages between nerve cells, which leads to symptoms of depression.

Some examples of SSRIs that are used to treat depression in people with MS include:

• Citalopram (Celexa)
  
• Paroxetine (Paxil)
• Fluoxetine (Prozac)
• Sertraline (Zoloft)

Serotonin and norepinephrine reuptake inhibitors (SNRIs) are another type of medication that can effectively treat depression. They are also useful for conditions like anxiety disorders and long-term pain. So, SNRIs may be of help to those with chronic pain (particularly nerve pain) as well as depression. Drugs in this class include duloxetine (Cymbalta) and venlafaxine (Effexor).

Some people also take medications from the aminoketone class of antidepressants. Bupropion (Wellbutrin SR, Wellbutrin XL) is the medication of this class that is most often used to treat depression in people with MS. Bupropion works similarly to SSRIs except that it blocks the nerves from absorbing too much of the neurotransmitters norepinephrine and dopamine.

Sexual Dysfunction

Sexual dysfunction can affect anyone with MS and can include erectile dysfunction, the inability to achieve orgasm, and low libido.

The medications used to treat sexual dysfunction in people with MS focus on erectile dysfunction and include:

• Sildenafil (Viagra)
• Tadalafil (Cialis)
• Vardenafil (Levitra)
• Alprostadil (MUSE, Prostin VR, Caverject, injectable)
• Avanafil (Stendra)
• Papaverine (off-label)

Tremors

Although tremors do not occur in everyone with MS, as many as 58% of people with the disease will experience the symptom at some point.

Tremors can present in different ways, such as a shaky voice, shaking that affects the arms and hands, and difficulty holding tools or utensils.

Some medications that can be used to treat tremors in people with MS include:  

• Baclofen
• Clonazepam (Klonopin)
• Dantrolene (Dantrium)
• Diazepam (Valium)
• Onabotulinumtoxin A (Botox)
• Tizanidine (Zanaflex)

Spasticity and Muscle Stiffness

The same medications that are used to treat tremors in MS can also be used to manage muscle stiffness and spasticity, including:

• Baclofen (Lioresal, Fleqsuvy): This medication acts on the nervous system to help reduce cramping, spasms, and tightness in the muscles that are caused by spasticity.
• Cyclobenzaprine (Amrix): This medication is designed to treat muscle spasms in people with conditions like carpal tunnel syndrome and tendinitis, but it can also relieve muscle tightness in people with MS.
• Dantrolene (Dantrium): This muscle relaxant relieves cramping, spasms, and tightness.
• Diazepam (Valium): This medication is a benzodiazepine (also known as central nervous system depressants). The main action of benzodiazepines is to slow the nervous system, which can help to relieve muscle spasms and spasticity.
• Onabotulinumtoxin A (Botox): The neurotoxin blocks connections that can help relieve muscle tightness and spasms.
• Tizanidine (Zanaflex): This drug relieves spasms, cramping, and tightness of muscles.

Vertigo and Dizziness

According to the National Multiple Sclerosis Society, vertigo and dizziness are common symptoms of MS. It can lead to people feeling off-balance or lightheaded, and may even increase the risk of people falling.

To treat vertigo and dizziness in people with MS, the medication meclizine (Antivert) is used. It is used to address dizziness, nausea, and vertigo in a variety of conditions.

Difficulty Walking and Gait Changes

Because of the way MS affects the central nervous system, many people with the condition can develop trouble walking and with mobility. When someone's ability to move around is affected by MS, their treatment plan will need to be adjusted to address it.

The medication that is typically used to help with walking or gait changes in people with MS is dalfampridine (Ampyra), an oral medication that works by improving signals in the nerves that have become damaged because of MS.

Summary

It can be challenging to cope with the various symptoms of MS, especially if they change as the disease progresses. However, there are a variety of different treatment options that can help manage symptoms and slow the progression of the disease, which will lead to a higher quality of life.

A Word From Verywell

The list of medications can be daunting, but know that having MS does not mean you will need to take every medication or undergo every treatment used for the condition. You may even change treatments from time to time throughout the course of the disease if your doctor thinks it will help you manage your symptoms more effectively or help slow the progression of the disease.