Medicine & Research

What to Expect from Your Disease-Modifying Therapy

By Dr. Daniel Kantor, M.D.

It’s time to set the record straight about MS disease-modifying therapies (DMTs), sometimes called disease-modifying drugs or agents (DMDs or DMAs). The way we treat MS is with a triple approach:

• DMTs (prevention)

• Symptomatic treatment

• Rescue therapy (shorten relapses)

Since MS is a lifetime diagnosis, symptoms may come and go; the idea is to prevent new problems while aiding in recovery from older problems. The most common form of MS is relapsing-remitting MS (RRMS). With this form, people are usually neurologically stable (in remission), but new neurological problems or relapses (such as weakness, visual problems, or walking problems) may occur for days to weeks to months.

We use rescue therapy, such as intravenous methylprednisolone or subcutaneous/intramuscular adreno-corticotropic hormone, to try to shorten the length of time of each relapse. We use symptomatic treatments to help you with your day-to-day symptoms, such as spasticity or muscle tightness, fatigue, pain, memory problems. This does not only include medications; there are a lot of complementary treatments, such as yoga, T’ai Chi, acupuncture, herbal remedies, etc., that are commonly used.

Some symptomatic therapies even go one step further and empower you by enhancing your life when you have problems with your neurological functioning; these neurofunctional enhancers (NFEs) are empowering because you (not a doctor, nurse, MRI scan, etc.) decide whether or not they are helping you within two months of starting them.

DMTs, on the other hand, are not designed to help day-to-day symptoms, nor can you necessarily tell on your own whether or not they are working. DMTs are FDA (U.S. Food and Drug Administration) approved to reduce the number of relapses, and sometimes to delay progression of disability. MS may lead to disability due to the accumulation of neurological problems with each relapse (after a relapse you may not fully return back to your previous baseline) or due to independent, slow progressive damage to nerves in the brain and spinal cord. Since everyone’s MS is different and since we don’t yet have biomarkers or predictors of how your MS will be in the future, when we start you on a certain DMT, we don’t know if you would have done just as well on another DMT.

So What Can Your DMT do for You?

The good news is that the FDA-approved DMTs have been consistently shown to help people control their MS. People with MS who take their DMTs as directed are more likely to have less relapses, less disability, and less changes on MRI scans. Recent research has explored the concept of sustained freedom from disease activity. For some people, the DMTs stop clinical relapses, disease progression, and MRI activity. As of December 2012, there are nine branded DMTs approved by the FDA.

To put it concisely: 

• DMTs are not cures

• DMTs are partially effective

• DMTs may cause side effects

• DMTs are not designed to control individual symptoms

• DMTs may reduce the number of MS relapses

• DMTs may reduce the severity of MS relapses

• DMTs may reduce the chances for progression of disability

• DMTs may prevent new or worsening MRI changes

• DMTs may prevent brain tissue loss (atrophy)

• DMTs may even lead to sustained freedom from disease activity 

Although DMTs are not FDA-approved to control individual MS symptoms, many people with MS report that their MS symptoms improve (and even disappear) once they are taking their DMTs for a while. We think that this happens because MS involves a person’s own immune system attacking itself. This neuro-inflammation can lead to symptoms originating from different parts of the central nervous system – the brain, optic nerves, cervical and thoracic spinal cord. DMTs not only modify MS by helping to prevent future relapses and disability, but also reduce inflammation by modulating the immune system. Reducing inflammation can lead to reduction in MS symptoms, and that is why some people feel better on their DMTs.

When You Don’t Feel Improvement

Sometimes, however, this benefit is counteracted by potential tolerability side effects that may make someone feel like their MS symptoms are not improving. This is why it is important to talk to your neurologist about how your DMT makes you feel and to discuss all of your options. If you stop taking your DMT on a regular basis but don’t tell your neurologist, then you may be making tolerability side effects more likely. (For example, flu-like symptoms seem to be worse when you don’t take the beta interferons consistently.)  Also, you are not taking advantage of the benefits of fully controlling your MS disease process.

If you aren’t having perfect control of your MS from your DMT, don’t despair. Your neurologist is well equipped and trained to help guide you through your options. There is presently no cure for MS, yet all of the DMTs are partially effective, and the benefit of staying on your current DMT may outweigh the risks of stopping it or of switching to another DMT. Sometimes, however, your neurologist may work with you on transitioning from one DMT to another.

Prior to 1993 there were no FDA approved DMTs. Just 20 years later there are nine branded options. Each of the DMTs has its own safety and tolerability profiles that need to be balanced against its level of effectiveness (both from clinical trials and from real-world experience). Internet searches, word of mouth from other patients, and even marketing materials from DMT manufacturers may be useful in understanding the pros and cons of a particular therapy for you. However, these (sometimes) biased sources of information should be balanced by counseling by your neurologist or MS specialist.

In summary, DMTs should not be confused with symptomatic treatments. DMTs are not cures, but they have changed the face of MS. The options available today are vastly expanded from what we had five, 10, 15, and 20 years ago. There is a much greater hope for the future than there ever has been in the past; this hope is continuously expanding with one to two new DMTs expected every year.

Deciding on which DMT is right for you is a joint decision made by you, your care partner, and your neurologist; sticking to your medication regimen is your ultimate responsibility.

Daniel Kantor, M.D. is the President of the Florida Society of Neurology, founder of the SouthEastern MS Consortium (seMSc) and medical director of Neurologique in Ponte Vedra, Fla. He is the former director of the Comprehensive MS Center at the University of Florida Jacksonville and he is a member of the healthcare advisory panel of the MSF and a member of the Pharmacy and Therapeutics Committee of Florida Medicaid. He is a principal investigator in multiple MS trials.

(Last reviewed 2/2013)