Regulation of immune system by suppressing expression of pro-inflammatory cytokines, promoting the expression of anti-inflammatory cytokines, and preventing inflammatory cells from entering the CNS
Serious: liver failure; mental health problems (including depression or suicidal thoughts); heart and blood vessel problems, seizures; and skin necrosis. Common: pain, swelling, flu-like symptoms; low white blood cell count (Betseron, Plegridy)
Copaxone, glatopa (glatiramer acetate)
Block immune system attack of myelin sheath, by shifting the balance between pro-inflammatory and Treg cells, and inhibits APCs by competing for myelin antigens
Serious skin necrosis, lipoatrophy, and liver failure. Common: pain/swelling/redness at injection site, flushing, trouble breathing, rash, and chest pain
Kesimpta (ofatumunab)
Selectively depletes CD20-expressing B cells
Hepatitis B Virus (HBV) reactivation can occur, in some cases resulting in fulminant hepatitis, hepatic failure, and death. Progressive multifocal leukoencephalopathy (PML) resulting in death. Neutropoenia, anaemia, thrombocytopenia. Common: Back pain, muscle aches, redness of the skin, and trouble sleeping
Oral DMTs
Gilenya (fingolimod)
Sphingosine 1-phosphate receptor modulators. This drug is believed to work by trapping T cells in the lymph nodes, preventing them from entering the brain and spinal cord
Serious: liver damage, severe worsening of MS following drug withdrawal, progressive multifocal leukoencephalopathy (PML), basal cell carcinoma, and melanoma. Macular edema, posterior reversible encephalopathy syndrome (PRES). Common: can slow the heartbeat, esp. initially
Mayzent (siponimod) and zeposia (ozanimod)
Similar to Gilenya (they modulate S1PR1 and S1PR5 on lymphocytes)
Serious: life-threatening infections, macular edema, PRES, liver, and breathing problems, severe worsening of MS after stopping the drug, basal cell carcinoma, and melanoma. Common: can slow the heartbeat, esp. initially headache, high blood pressure, and abnormal liver tests (common with Mayzent), upper respiratory tract infections, increased liver enzymes, back pain, orthostatic hypotension, headache, high BP, painful, and frequent urination (zeposia)
Tecfidera (dimethyl fumarate)
Anti-inflammatory and antioxidant properties (via activation of NRF2 and inhibition of GAPDH) that help protect against damage to the brain and spinal cord
Serious: allergic reactions, PML, a lowering of your white blood cell count, liver problems, herpes zoster infection (shingles), and other serious infections. Common: flushing, redness, itching, rash, nausea, vomiting, diarrhea, stomach pain, and indigestion
Vumerity (diroximel fumarate)
Similar to tecfidera but has been found to be better tolerated with fewer gastrointestinal side effects
Serious: allergic reactions, PML, a lowering of your white blood cell count, liver problems, shingles, and other serious infections. Common: flushing, redness, itching, or rash and stomach problems, including nausea, vomiting, diarrhea, pain, or indigestion
Bafiertam (monomethyl fumarate)
Similar to tecfidera and vumerity but improved gastrointestinal tolerability
As for vumerity (diroximel fumarate)
Aubagio (teriflunomide)
Blocks mitochondrial respiration by inhibiting dihydro-orotate dehydrogenase, thereby reducing activated T and B cell proliferation
Serious: low white blood cell count, more frequent infections, numbness and tingling in the hands or feet, high blood pressure, allergic reactions, potentially life-threatening skin reactions, new or worsening breathing problems. Common: headache, diarrhea, nausea, hair thinning or loss (alopecia), and abnormal liver blood tests
Mavenclad (cladribine) (generally only recommended for patients who do not tolerate or respond to other DMTs)
Temporarily reduces the number of T and B lymphocytes by impairing DNA synthesis/repair and inducing cell death (is a deaminase-resistant adenosine analog)
Serious: low blood cell counts, increased risk of cancer, serious infections (e.g., tuberculosis, hepatitis B or C, shingles, or PML), liver problems, allergic reactions. Common: upper respiratory infections, headache, and low white blood cell counts
Ponvory (ponesimod)
S1R1 on lymphocytes is selectively modulated to prevent their exit from lymphatic tissue
Lemtrada (alemtuzumab) (Due to safety concerns, the FDA recommends this drug be reserved for patients who do not respond to two or more other DMTs)
A monoclonal antibody that targets lymphocytes via CD52. (Can also deplete some subsets of myeloid cells)
Serious: immune thrombocytopenic purpura (ITP) in which the body attacks the platelets, and kidney problems, serious infusion reactions, stroke, and tears in carotid and vertebral arteries, increased risk of certain cancers. Hyper- or hypothyroidism, low blood cell counts, liver inflammation, hemophagocytic lymphohistiocytosis, thrombotic thrombocytopenic purpura (TTP), bleeding disorders, serious infections (e.g., PML, tuberculosis, listeria), acalculous cholecystitis, and pneumonitis. Common: skin rashes, swelling of nose and throat, nausea, vomiting, diarrhea, musculoskeletal and neurologic pain, and thyroid problems
Novantrone (mitoxantrone)
Antineoplastics (anticancer/chemotherapy). It reduces the activity of T cells, B cells, and macrophages (through DNA intercalation leading to cross-links and strand breaks) to prevent them from attacking the myelin
Serious: AML, heart toxicity specifically heart failure. Common: nausea, hair loss, menstrual changes, upper respiratory, and urinary tract infections, mouth sores, irregular heartbeat, diarrhea/constipation, back pain, headache, and blue–green urine
Tysabri (natalizumab)
A monoclonal antibody that blocks VLA4, preventing potentially harmful immune system cells from crossing the BBB into the CNS
Serious: PML, herpes infections, liver damage, allergic reactions, weakened immune system and higher risk of infections, and low platelet counts. Common: headache, nausea, diarrhea, urinary tract/lung/nose and throat infections, depression, extreme tiredness, joint pain, vaginitis, and rashes
Ocrevus (ocrelizumab)
A monoclonal antibody that targets CD20-positive B lymphocytes, depleting them
Serious: severe infusion reactions, infections (e.g., herpes viral, PML, and reactivation of hepatitis B), weakened immune system, and risk of cancer, including breast cancer. Common: upper respiratory tract infections and infusion reactions in RRMS patients; upper/lower respiratory tract infections, skin infections, and infusion reactions (PPMS patients)
Briumvi (ublituximab)
A monoclonal antibody that targets CD20-positive lymphocytes
Serious: severe infusion reactions and infections (e.g., herpes virus, PML, and reactivation of hepatitis B) Common: upper and lower respiratory tract infections, infusion reactions, and herpes infections
Rituxin or MabThera (rituximab) Administered under close supervision of physician
A monoclonal antibody that targets CD20-positive lymphocytes (B cells)
Serious: immunoglobulin deficiency syndromes can occur that may be associated with severe infections, progressive multifocal leucoencephalopathy (PML), a rare but serious brain infection caused by a virus, can occur in people with prior or having concurrent immunosuppressive therapy, although the chances are listed as “no or very low risk,” hypotension, hypertension, arrhythmias, and angina. Common infusion-related reactions, esp. after the initial dose
Not officially used for treatment of MS but is administered off-label by several neurologists for relapsing forms of MS. It is approved for treatment of adults with B cell non-Hodgkin’s lymphoma, chronic lymphocytic leukaemia, rheumatoid arthritis, granulomatosis with polyangiitis (Wegener’s granulomatosis), microscopic polyarteritis, and pemphigus vulgaris.
