Available immunotherapies for multiple sclerosis

Immunotherapy is indicated for patients with relapsing forms of multiple sclerosis and active disease. When starting immunotherapy, the expert chooses the drug after considering the relative harms and benefits to the patient and having an informed discussion with them. Historically, the approach has been to start therapy with the safest drugs, before scaling up to more potent drugs that have higher risk. However, when using this approach, careful monitoring is needed to ensure that the disease does not progress and cause damage. Increasingly, the approach to therapy is to give highly effective treatment early, so the patient achieves a target called NEDA (no evidence of disease activity)—with NEDA, the patient is stable clinically, and has no relapses and no new lesions on magnetic resonance imaging.

Patients at high risk of disability start early on more potent but higher risk therapies—these are alemtuzumab, natalizumab and ocrelizumab, which are monoclonal antibody drugs given intravenously. Drugs given orally (eg dimethyl fumarate, fingolimod, teriflunomide) have moderate potency. The older drugs, interferons (subcutaneous) and glatiramer acetate (subcutaneous), work well in some patients. However, the effect of these older drugs is less predictable, and relapses are more common than with monoclonal antibody and oral drugs. Immunotherapies available for MS (other than ocrelizumab) are shown in #nrg5-c27-s4__tnrg5-c27-tbl2a, with reported efficacy and the most serious adverse effects.

Precautions before starting immunomodulatory therapy (eg pretreatment screening and vaccination), and during therapy, are described in the Product Information for each drug. For guidance on when to give antimicrobial prophylaxis for patients taking immunotherapy, see Assessing the need for antimicrobial prophylaxis in immunocompromised adults without HIV infection. For further information, consult local protocols or seek expert advice.