Let's Talk About MS Treatment
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There may not be a cure for multiple sclerosis quite yet, but there are so many reasons for hope. Thanks to a better understanding of MS risk factors, plus staggering advances in scientific research and medication development, people with MS now have a better chance than ever to live well—and even thrive—with this disease. If you’ve been diagnosed with MS, you and your medical team will fight MS on multiple fronts. We’re here to help guide you on different treatment options and approaches. Read on.
Wait, What's MS Again?
Multiple sclerosis is a type of autoimmune disease that affects the myelin sheath, the protective tissue that surrounds nerves. For reasons that aren't exactly clear, somehow the body mistakes myelin for a foreign invader and launches an immune attack against it, eventually causing scars (or scleroses) in the brain, spinal cord, or optic nerves. It's this damage that contributes to some of the common MS symptoms, like numbness, pins and needles, and blurry vision. Why? They interrupt the signals traveling from the brain.
There are several types of MS, but the most common one is called relapsing-remitting (RRMS), and it's characterized by periods of disease activity (the relapses) followed by periods of remission. Some people with RRMS may go on to develop secondary progressive (SPMS). During this later stage of the disease (it's typically diagnosed at least 10 years after RRMS and often much later), nerve damage tends to slowly accumulate without any periods of remission. The most rare type of MS is primary progressive (PPMS). Symptoms and disability tends to build steadily from the start, with few or no remissions.
What Are the Treatments for MS?
With no known cause, multiple risk factors, and a constellation of potential symptoms, a condition like MS requires more than one treatment approach. That's because your experience with MS is unique to you. The approach that worked for your friend with MS may not be the one that works for you, and vice versa.
But what’s most important to know is that a range of new therapies—many of which were not available even a generation ago—enable many people with MS to take more control of their symptoms (and their lives), supplemented by a healthy diet, active lifestyle, stress management, and other daily choices that put physical and emotional well-being first.
Let’s take a look at some of the options available to treat your MS.
Disease-Modifying Therapies (DMTs) for Relapsing-Remitting MS
Perhaps no area has caused more excitement and hope than DMTs. A mere 25 years ago, drugs that slowed the progression of multiple sclerosis did not exist.
Now, people diagnosed with relapsing-remitting MS have multiple options to choose from. There are even new treatments for people with the progressive forms of the disease (more on these below).
DMTs work to alter the inflammation process, primarily by slowing the production of immune cells that attack myelin. Less inflammation, means less scarring. Less scarring means fewer flares. These drugs are usually classified by how they’re delivered:
INJECTIONS Betaseron (interferon 1b), the very first DMT, changed the face of MS treatment with its FDA approval back in 1993.
You inject Betaseron and similar DMTs like Copaxone (glatiramer acetate) yourself, directly under the skin or into a muscle, daily or a few times a week, depending on what your doctor prescribes.
Since these medications have the benefit of nearly three decades of use, they are not only well-studied, they are considered effective and safe.
Side effects are generally mild—some people experience irritation at the injection site and/or flu-like symptoms—although most people have few or no adverse effects. These first-wave DMTs have become the standard to which newer treatments are compared.
INFUSIONS Like injections, infusions are delivered via needle, but instead of going under the skin or into a muscle, they go directly into the bloodstream through an I.V. drip.
Your healthcare provider will give you infusion treatments a few times a year. Infusion medications such as Tysbari (natalizumab) and Ocrevus (ocrelizumab) can slow down MS and disability even more than injections because they target the specific proteins that are driving inflammation. In other words, they aim to cut it off at the source.
ORAL MEDICATIONS Pills like Gilenya (fingolimod) and Mayzent (siponimod) are also used to treat people with MS.
Many people find taking a pill once or twice a day to be less annoying than a daily shot. Plus, they slow MS progression as well as infusion and are even better than older meds at staving off relapses.
Like all medications, DMTs for MS have potential side effects, including some serious ones like an increased risk for certain infections, heart disease, and liver problems. Your doctor will review all the risks and benefits for any recommended treatment with you (including options that fit best with your lifestyle), and if they don't, be sure to ask!
These powerful anti-inflammatories can be delivered as pills, shots, inhalers or topical creams. And if you're having a monster flare, steroids are pretty effective at quickly taming that MS beast. However, they're not meant to be used long-term because they can bring a host of side effects, including:
- Stomach pain and indigestion
- A metallic taste in your mouth
- Mood swings, anxiety, restlessness
- Increased appetite
- Palpitations (a faster than normal heart rate)
- Chest pain
To prevent the effects of long-term treatment, your medical team will likely give you no more than three courses of steroids in one year. However, if steroids don't do the the trick, your doctor may suggest plasmapheresis, which is a fancy term for recycling your own blood. Plasmapheresis actually replaces your blood, or at least part of it. It works like this:
- Doctors draw your blood from a large vein.
- The blood goes into a centrifuge or filtration system to separate the liquid (plasma) from the red and white blood cells.
- The cells are mixed with a plasma-replacement fluid and then put back into you.
The idea is that when the plasma is removed, some of the antibodies that attack myelin—the process at the heart of MS—hitch along for the ride and also get removed. The American Academy of Neurology (AAN) recommends plasmapheresis for RRMS relapses when steroids haven’t worked. It recommends against plasmapheresis for PPMS because it’s been shown to be ineffective.
DMTs for Progressive Forms of MS
To refresh: disease-modifying therapies (DMTs) reduce the number of relapses and lesions on the brain, ultimately curbing long-term disability by preventing damaging inflammation.
Ocrevus (ocrelizumab), the first therapy approved for RRMS as well as primary and secondary progressive MS hit the market in 2017. Compared to a placebo, this infusion cut the risk of progression by a quarter and boosted walking speed by 29%, according to results from one study. This medication reduces the number of certain B cells, which are immune cells that likely play a role in damaging myelin and causing lesions.
While Ocrevus is so far the only drug approved for PPMS, these are additional options for SPMS: Mavenclad (cladribine); Mayzent (siponimod); and Novantrone (mitoxantrone).
How Can I Treat MS Symptoms?
Drugs used to manage MS symptoms are part of a comprehensive MS treatment plan. Of course, treatment for symptoms depends on what your symptoms actually are! Since MS is so individualized, we’ll only cover the most common ones here.
Fatigue is one of the most frequent symptoms of MS. And we're not talking about the kind of tired you feel when you stay up too late. MS can lead to a level of exhaustion that makes it impossible to get out of bed, even after you've slept and slept. In fact, there's a name for that: lassitude. Doctors aren't exactly sure what causes it, but it's likely that all that inflammation that's happening in your body literally tires you out. It's also possible that sleep disturbances, depression, even your medications are compounding the problem.
Depending on what you're dealing, your doctor may prescribe a range of medications to help. They include:
- Antidepressants to treat underlying mood disorders; more on these below.
- Stimulants such as Provigil (modafinil) and Nuvigil (armodafinil) to promote wakefulness and fight sleepiness. Originally developed for people with narcolepsy and other sleep disorders, they're usually prescribed at lower doses in people with MS. ADHD medication, including Ritalin (methylphenidate), can also help people with MS focus and feel more energized when they’re experiencing fatigue.
- Antivirals such as Symmetrel (amantidine) to increase the amount of the neurotransmitter dopamine in the brain. Dopamine may help tamp down the overactive immune cells that are a hallmark of MS. Fewer of those hyped up immune cells can mean less fatigue.
It's really not fun to have the muscles in your arms, legs, back or torso clench randomly and involuntarily, and it's something that most people with MS have to deal with at some point. Spasticity occurs when the nerve messages to the muscles get scrambled, leading to pain, balance problems, and walking trouble.
To treat it, your doctor may prescribe muscle relaxants. These drugs work on the CNS to, yep, relax muscles to prevent them from clenching and twitching. They come in pill form or as a surgically implanted pump that delivers the medication directly to the spinal cord.
Depression is one of the most common co-occurring conditions (a.k.a., comorbidities) of MS, and if you're struggling emotionally, psychotherapy is an excellent place to start. Your therapist may choose any numbers of approaches, including talk therapy and “behavioral activation”—which involves creating a plan to do things you enjoy—and then actually doing them. You might literally schedule activities like "play my guitar for 30 minutes" or "go for a walk after dinner" into your calendar. It's all about building motivation and setting goals. You can also think of it an anti-wallow distraction plan. You'll be too busy doing stuff. Some studies suggest up to half of all people with MS will become clinically depressed at some point, and if that happens to you, this approach—chasing your joy—can help to combat low mood.
That said, the inflammation that causes MS can also create mood changes that require medication. Working with a therapist can help you figure that out, too.
Antidepressants help combat depression by improving transmission of signals between neurons. And, they’ve also been shown to curb inflammation by slowing the production of immune cells and causing them to die off sooner than normal. Treating depression with medication may also help with other symptoms associated with MS. That’s because many drugs for depression treat MS-related fatigue and chronic pain, too.
Incontinence happens in MS when nerves that control the bladder, bowels, or pelvic floor become damaged.
When that happens, the bladder sometimes squeezes and forces urine out. Antispasmadic drugs such as Oxytrol (oxybutinin) may help the bladder relax to produce fewer squeezes. Botox (botulinim toxin) injections can help block nerve signals to the bladder, which have become erratic due to damage from MS, and improve symptoms. And Kegel pelvic exercises may help strengthen the pelvic floor to prevent incontinence.
For bowel incontinence, most healthcare providers recommend lifestyle treatments to keep you “regular,” such as a high-fiber diet, physical activity, and plenty of fluids. Additional treatments you can explore with your doctor include biofeedback training, which help you become more aware of when you have to go, as well as transanal irrigation, which helps flush stool out. We know, no one wants to even think about this problem, but just remember that there are treatments.
Insomnia can have a lot of possible causes when you have MS, such as:
- Side effects of medication
- Napping during the day due to fatigue
- Chronic pain or uncomfortable spasticity
That means you’ll need a multipronged approach to deal with insomnia. Start with healthy sleep hygiene (more on this in the very next section). And be sure to seek treatment for other MS symptoms, such as depression and pain, that may be stealing your snooze time.
If you’re still not getting the sleep that you need talk to your doctor, who might suggest you try:
- Melatonin supplements, which are made from a natural hormone in the brain that helps prepare you for sleep.
- Antihistamines like Benadryl (diphenhydramine HCI), which can make you drowsy.
- Sleep medications like Ambien (zolpidem)—but do make sure your doctor is aware of all other current medications to avoid a negative interaction.
What Lifestyle Changes Can I Make to Support My MS Treatment?
MS may throw some challenges your way, but it doesn’t take away your free will. So, choose to put your physical and emotional health first. Since MS is such a personalized disease, there’s no one-size-fits-all lifestyle plan. People with MS might have to work within the limits of their condition, sure, but most of us have some control over:
- How we sleep
- How we fuel our bodies
- How we move our bodies
- How we spend our time
- How we engage our minds
- How we manage stress
These tips can help maximize your medical treatment so you feel as healthy and strong as possible.
Make Sleep a Priority
If you’re living with MS, healthy sleep hygiene is essential—maybe more for you than for most people. Yet, because of your condition, it may be harder to come by quality, consistent Zzzs.
Problems with insomnia, spasticity, stress, nerve pain, and depression can all contribute to your not getting enough shuteye—even when shuteye is exactly what you need most to combat the fatigue that comes with a disease flare (and sometimes outside of one). Here’s what you can do to get your nightly, needed 8 hours:
- Establish a Bedtime Ritual: Going to bed and waking up at approximately the same times each day—even on the weekends!—helps you set your circadian rhythm, the body’s inner clock, which may set you up for a better night’s sleep. Lights out!
- Limit Caffeine: Stimulants like caffeine can keep you tossing and turning. Keep your java, tea, or cola intake to one (or, at most) two drinks in the morning for better shuteye later on.
- Avoid or Limit Alcohol: If you have MS and enjoy the occasional cocktail—try to have the last one a few hours before bedtime to allow enough time for the alcohol to metabolize. Alcohol is known to disrupt sleep.
- Stay Calm: Meditation, when we intentionally clear our minds of the day’s thoughts and troubles, has been shown to help reduce stress, which in turn promotes good sleep. Check out the Calm or HeadSpace apps for pre-bedtime mindfulness tips.
- Limit Liquids: People with MS often have to get up more than once in the night to urinate. Do your best to limit liquids for a few hours before going to bed.
- Exercise Regularly: Get better rest from a regular workout—just be sure to finish exercising four to six hours before hitting the sheets or your upped energy just might leave you tossing and turning.
- Turn Off Blue-Lit Screens: The blue light emitting from most digital screens activates your brain in the same way sunshine does—triggering a wakeful response. So put down your phones and tablets at least an hour before bed.
- Use the Bed for Sleep and Sex Only: No work! You don't want to have the place where you're supposed to be the most relaxed associated with any kind of stress. It's for sleeping and getting it on. That's it.
Focus on Your Nutrition
If you’re looking for a diet specifically tailored to help MS symptoms, you won’t find one. However, here are some good guidelines for anti-inflammatory, healthy eating (and drinking):
- Eat More Low-Fat Dairy: People with MS are at higher risk for low bone density from osteoporosis. This may be due symptoms of weakness that prevent much weight-bearing exercise, as well as certain medications used to treat MS that can lead to bone loss. The National MS Society recommends 1,000 mg of calcium per day for adults ages 25 to 65 and 1,500 mg per day for postmenopausal women, preferably from calcium-rich food sources like low-fat milk, yogurt, and cheese. These foods are also fortified with vitamin D, which may help reduce MS-related symptoms
- Dine on Fatty Fish: Omege-3 fatty acids found in fish like salmon, tuna, and sardines are shown to help fight inflammation in the body. Australian researchers found that the more fish people with MS eat, the less disease activity and fewer relapses they experience.
- Enjoy More Fruits and Veggies: Plants, especially colorful ones, are good for you. And a high-fiber diet is especially good for people with MS because it can help relieve constipation. Fruits and veggies are also rich in antioxidants like vitamins C, E, and A, which help tame inflammation.
- Try Fermented Foods: Sauerkraut, kefir, kimchi, and yogurt are rich in probiotics, good-for-you-kind bacteria. Aim for at least one kind of fermented food each day.
- Reach for More Nuts and Seeds: Why? Because nuts and seeds are rich in biotin, a kind of B vitamin that’s been shown to help improve symptoms of MS.
- Skip the Salt Shaker: The more sodium people with MS have in their systems, the more likely they are to relapse, according to a Harvard study. Salt can also raise your blood pressure, too. So set down the salt, limiting it to no more than 2,300 mg (one teaspoon) per day, or 1,500 mg (three-quarters teaspoon), if you already have heart disease.
- Eat (and Drink) Less Sugar: Refined sugar triggers inflammation in the body. And it’s found in our processed and packaged foods: breakfast cereals, snacks, condiments like ketchup, and sweetened beverages, too. One study shows how people with MS who drank two cans of soda or sweetened beverages per day experienced more frequent and severe symptoms. Do you best to limit—or even eliminate!—refined sugars from your diet. Alcohol—wine, beer, spirits—often contains a lot of sugar, too.
It’s worth noting that people with MS are more likely to have other chronic diseases such as high blood pressure (HBP), high cholesterol, and type 2 diabetes. Keep those in mind as well when you’re making your day-to-day diet choices. And guess what the standard diet advice is for those diseases? Yep, all of the above.
Exercise on the Regular
When you’re exhausted and in pain during an MS relapse, you may think activity could only make everything worse. It’s actually the opposite. Exercise helps in almost every way. People with MS who exercise:
- Preserve Brain Function: Moving your body may actually help you better maintain your brain—and even stave off the progression of damage to it. In a 2018 study published in the Multiple Sclerosis Journal, researchers found that when people with MS performed twice-weekly resistance-training workouts (strength training or swimming are both good) for 24 weeks, MRI scans showed that overall brain damage from MS had not progressed. Meanwhile, certain parts of the brain had actually thickened, suggesting an exercise regimen helped preserve brain tissue, and in some cases, may have promoted brain regeneration.
- Fight Weakness and Build Strength: A common symptom of MS is a feeling of weakness, which comes from interrupted nerve signals from the brain to the muscles, compounded by lowered endurance from not using these same muscles as much as you once did. Try resistance training (strength training, yoga, or swimming are all good) to help retain, and even build upon, strength.
- Improve Balance and Coordination: People with MS may experience unsteady walking, spasticity, and difficulty with balance and muscle coordination. Without exercise, these symptoms can worsen. But research shows that those who engage in daily exercise can improve such symptoms. Hit the mat to stretch and do some downward dogs, take to the streets for a nice walk, or jump in the pool to swim a few laps. (You can work these balance moves into your routine, too.)
- Up Energy Levels: Major fatigue is common in people with MS and can even occur outside a relapse or attack. One study shows how 45 minutes of swimming three times each week improved symptoms of fatigue in women with MS, compared women with MS who did not exercise in this way. Go on, dive in.
- Protect Bone Density: Bone health can be an issue for people with MS, due to reduced physical exercise and muscle strength from nerve conduction issues, lower levels of vitamin D, as well as some MS medications that can strip bone density. So it makes sense that weight-bearing exercises like daily walking and yoga may be especially helpful.
- Improve Bladder Control: Incontinence—when you pee with urgency, and all too frequently—is a typical symptom of MS. Studies show how pelvic floor training (also known as kegel exercises) can help women with MS who regularly battle with their bladders improve their symptoms.
- Boost Mood: Clinical depression is more common in people with MS than in the general population—and regular exercise has been shown to improve symptoms of low mood.
A few additional notes on working up a sweat: Although exercises for MS are largely the same as those that people without MS do, it’s important to work within any limitations of your disease. If your symptoms are dizziness and vertigo, for instance, you might do better on a stationary bike instead of a treadmill.
Water exercises are often favored by people with MS. Water walking and water aerobics can be easier on the joints than their dry-land counterparts—just make sure the water’s not too hot. In fact, heat is something you’ll have to watch closely, since symptoms can flare up or become worse when your body overheats.
If it’s feasible, seek out a physical therapist, especially one who’s worked with people who have MS, who can modify exercises appropriately. Always follow your doctor’s instructions—and, have fun! Remember: The point is to feel good.
Work Out Your Brain
Cognitive decline can be a big issue for people with MS. In fact, 65% of people with this disease sometimes have trouble focusing, processing information, and struggling with memory. The good news?
There are ways to help combat cog fog with what’s called our cognitive reserve, the brain’s backup system to form new connections, and to change and adapt. (Everyone has it, not just people with MS.) However, this reserve is not unlimited—it can only do so much. So help your brain health by doing any and all of the following:
- Read More: Reading stimulates many parts of the brain—which is good for yours! In fact, one study from Emory University suggests that reading may increase connectivity in the brain, improving brain function for at least a few days. Even a graphic novel, the sports section, or your favorite entertainment news can do the trick. Just read!
- Get Lost in Thought: Doing puzzles, playing memory games, learning a new language, or even balancing your checkbook in your head all help fight cognitive decline. One study published in Neurology shows how the more people with MS do these sorts of things, the less they experience cognitive symptoms.
- Be Social: Join a book club. (Reading!) Work out with a friend. Attend a church gathering or support a cause or foundation that speaks to your specific interests. When we’re social, we’re engaging our brains in many different ways, including the parts responsible for attention, language comprehension, and working memory—which all help boost cognitive reserve, the backup system in our brains.
Take Stress Management Seriously
Can stress cause a relapse of MS? The scientific jury is still out on this question, but many people with MS report additional symptoms during particularly stressful times. We do know that unmanaged stress can negatively affect the central nervous system—and that’s what you’re most trying to protect if you have MS.
Common signs of stress include:
- Constant worry and expecting the worst to happen
- Sleep disturbances, or sleeping too much or too little
- Difficulty making decisions
- Chronic irritability
- Feeling down or demoralized
- Feeling overwhelmed
- Heart palpitations
- Clammy hands
If you have MS, stress management is an important part of managing your disease. Talk with your family, friends or a counselor, join a support group, learn to manage your anger and fears through stress-busting mindfulness and meditation, and consider exercising more, which has been shown to reduce feeling of stress.