DMT Treatment Options for Multiple Sclerosis

Disease-Modifying Therapy Comparison and Side Effects

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In multiple sclerosis (MS), a person's immune system attacks the protective covering (myelin sheath) of nerve fibers in the brain and spinal cord (central nervous system). MS disease-modifying therapies (DMTs) are medications that disrupt these misguided attacks. DMTs are available in three different forms—injections, oral therapies, and IV infusions.

Most are approved to treat relapsing forms of MS in adults. This includes relapsing-remitting MS (the most common form, with periods of symptom relapses and remissions), active secondary progressive MS (with steadily worsening symptoms and few or no remissions), and clinically isolated syndrome (one neurological event with symptoms and signs of MS).

This article will compare the numerous DMT options available, including their unique side effect profiles.

DMTs for MS Come in All Forms

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DMT vs. Symptom Management

DMTs are drugs to improve the long-term outlook of the condition. They reduce the number and severity of MS relapses and slow down the natural progression of the disease.

Starting a DMT Soon After Diagnosis

Research indicates that early treatment with DMTs plays a key role in delaying disability and disease progression.

DMTs are not used to treat individual relapses or daily MS symptoms.

Moderate to severe MS relapses are typically treated with a high-dose, anti-inflammatory corticosteroid like Solumedrol (methylprednisolone) or prednisone.

The symptoms of MS, like fatigue, bladder dysfunction, pain, and walking problems, are treated with various symptom-targeted medications and/or rehabilitation therapies.

Injectable DMTs

Injectable DMTs are given as a shot either into one of your muscles (intramuscular) or beneath your skin (subcutaneous).

Beta Interferon Drugs

Interferons are proteins that your body makes naturally to help regulate your immune system.

Beta interferon drugs are used to treat relapsing forms of MS. They include:

  • Avonex, Rebif (interferon beta-1a)
  • Betaseron, Extavia (interferon beta-1b)
  • Plegridy (peginterferon beta-1a)

How They Are Taken

Administration of these drugs includes:

  • Avonex is injected intramuscularly once a week.
  • Betaseron and Extavia are injected subcutaneously every other day.
  • Rebif is injected subcutaneously three times a week.
  • Plegridy is injected subcutaneously or intramuscularly every 14 days.

Side Effects

Common side effects of beta interferon drugs include:

  • Injection site reactions: Swelling, pain, or redness of the skin at the site where the drug is injected.
  • Flu-like symptoms: Chills, fever, muscle pain, unusual tiredness, weakness, and/or headache

Betaseron and Extavia may also cause a low white blood cell count. This can make you more vulnerable to infection.

Skin breakdown (damage to the skin's surface) at the injection site, trouble sleeping, belly pain, and increased liver enzymes (seen on a blood test) may also occur with Betaseron and Extavia.

Potential serious side effects of all the beta interferon drugs include liver failure and mental health problems, including depression or suicidal thoughts.

Some of the drugs may also cause heart and blood vessel problems, seizures, and skin tissue death (necrosis).

Copaxone, Glatopa

Copaxone and Glatopa (glatiramer acetate) are also injectable drugs. They block your immune system from attacking the protective myelin sheath covering of nerves and are used to treat relapsing forms of MS in adults.

How They Are Taken

Copaxone and Glatopa are injected subcutaneously either every day or every three days (a higher dose is used).

Side Effects

The most common side effects associated with Copaxone and Glatopa are redness, pain, and swelling at the injection site, along with flushing, trouble breathing, rash, and chest pain.

Potential serious side effects include skin necrosis, lipoatrophy (loss of fatty tissue beneath the skin), and liver failure.

Summary of Injectable DMTs
 DMT  How It's Taken Common Side Effects
 Avonex, Rebif (interferon beta-1a) Injected intramuscularly once a week (Avonex) or subcutaneously three times a week (Rebif) Injection site reactions and flu-like symptoms
Betaseron, Extavia (interferon beta-1b) Injected subcutaneously every other day Injection site reactions and flu-like symptoms 
Plegridy (peginterferon beta-1a) Injected subcutaneously or intramuscularly every 14 days Injection site reactions and flu-like symptoms 
Copaxone and Glatopa (glatiramer acetate) Injected subcutaneously either every day or every three days Injection site reaction, flushing, trouble breathing, rash, and chest pain

Oral DMTs

Oral DMTs may be a reasonable choice for patients who prefer to take a pill rather than undergoing injections or infusions.

Gilenya

Gilenya (fingolimod) belongs to a class of drugs called sphingosine 1-phosphate receptor modulators. This drug is believed to work by trapping certain immune system cells in the lymph nodes, preventing them from entering the brain and spinal cord.

Gilenya is approved to treat relapsing forms of multiple sclerosis (MS) in adults.

First Pediatric DMT Approval

Gilenya is also approved to treat children and adolescents with relapsing MS who are 10 years of age and older.

How It's Taken

Gilenya is taken once a day by mouth with or without food.

Gilenya can slow down your heartbeat, especially when you first start it. As a result, you will have an electrocardiogram (ECG) before you take your first dose. You will also be monitored by a healthcare professional for at least six hours after your first dose.

Side Effects

The most common side effects of Gilenya are headache, abnormal liver tests, diarrhea, cough, flu, inflammation of the sinuses (sinusitis), and pain in your back abdomen, arms, or legs.

Potential serious side effects include:

A vision problem called macular edema and a condition called posterior reversible encephalopathy syndrome (PRES) where the blood vessels in your brain become swollen and narrowed may also occur.

Mayzent and Zeposia

Mayzent (siponimod) and Zeposia (Ozanimod) work similarly to Gilenya and are approved to treat relapsing forms of MS in adults.

How They're Taken

Mayzent and Zeposia are pills taken once a day by mouth with or without food.

With Zeposia (to prevent increasing your blood pressure), you will be asked to avoid meals or snacks that are high in tyramine like aged, fermented, cured, smoked, and pickled foods.

Mayzent and Zeposia may slow your heart rate when you start taking it. As with Gilenya, an ECG is required before your first dose.

Side Effects

The most common side effects of Mayzent are headache, high blood pressure, and abnormal liver tests.

Potential serious side effects include life-threatening infections, macular edema, PRES, liver and breathing problems, severe worsening of your MS after stopping the drug, basal cell carcinoma, and melanoma.

With Zeposia, the most common side effects are:

Potential serious side effects of Zeposia include life-threatening infections, macular edema, PRES, liver and breathing problems, and severe worsening of your MS after stopping the drug.

Tecfidera

Tecfidera (dimethyl fumarate) is approved to treat relapsing forms of MS in adults. Tecfidera is believed to have anti-inflammatory and antioxidant properties that help protect against damage to the brain and spinal cord.

How It's Taken

Tecfidera is taken twice daily by mouth with or without food.

Side Effects

The most common side effects of Tecfidera are flushing, redness, itching, rash, nausea, vomiting, diarrhea, stomach pain, and indigestion.

Potential serious side effects include allergic reactions, PML, a lowering of your white blood cell count, liver problems, herpes zoster infection (shingles), and other serious infections.

Vumerity

Vumerity (diroximel fumarate) is similar to Tecfidera but has been found to be better tolerated, especially when it comes to gastrointestinal side effects. Like Tecfidera, Vumerity is approved to treat relapsing forms of MS in adults.

How It's Taken

Vumerity is taken twice daily by mouth. If taken with food, you will need to avoid high-fat, high-calorie meals or snacks.

Side Effects

The most common side effects of Vumerity are flushing, redness, itching, or rash and stomach problems, including nausea, vomiting, diarrhea, pain, or indigestion.

Potential serious side effects include allergic reactions, PML, a lowering of your white blood cell count, liver problems, shingles, and other serious infections.

Bafiertam

Bafiertam (monomethyl fumarate) is similar to Tecfidera and Vumerity and is approved to treat relapsing forms of MS in adults.

How It's Taken

Bafiertam is taken twice daily by mouth with or without food.

Side Effects

The most common side effects of Bafiertam are flushing, redness, itching, or rash, nausea, vomiting, diarrhea, stomach pain, or indigestion.

Potential serious side effects include allergic reactions, PML, a lowering of your white blood cell count, liver problems, shingles, and other serious infections.

Aubagio

Aubagio (teriflunomide) blocks the function of certain immune system cells involved in MS and is used to treat relapsing forms of MS in adults.

How It's Taken

Aubagio is taken once a day with or without food.

Side Effects

The most common side effects of Aubagio are headache, diarrhea, nausea, hair thinning or loss (alopecia), and abnormal liver blood tests.

Potential serious side effects include:

  • 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

Mavenclad

Mavenclad (cladribine) temporarily reduces the number of T and B lymphocytes (types of white blood cells involved in immune reactions) in your body. Mavenclad is approved to treat relapsing-remitting MS and active secondary progressive disease in adults.

Due to safety concerns, it's generally recommended only for patients who cannot tolerate or who do not respond to other DMTs.

How It's Taken

Mavenclad is taken by mouth in two yearly treatment courses. Each yearly treatment course consists of two cycles (lasting four or five days) that are about a month apart.

Side Effects

The most common side effects of Mavenclad are upper respiratory infections, headache, and low white blood cell counts.

Potential serious side effects include:

  • Low blood cell counts
  • Increased risk of cancer
  • Serious infections (e.g., tuberculosis, hepatitis B or C, shingles, or PML)
  • Liver problems
  • Allergic reactions
Summary of Oral DMTs
 DMT How It's Taken  Common Side Effects
Gilenya (fingolimod) By mouth once a day Headache, abnormal liver tests, diarrhea, cough, flu sinus inflammation, pain in your back pain, abdomen, arms, or legs
Mayzent (siponimod) By mouth once a day Headache, high blood pressure, and abnormal liver tests
Zeposia (Ozanimod) By mouth once a day Upper respiratory tract infections, increased liver enzymes, back pain, orthostatic hypotension, headache, high blood pressure, and painful/frequent urination.
Tecfidera (dimethyl fumarate) By mouth twice daily Flushing, redness, itching, rash, nausea, vomiting, diarrhea, stomach pain, and indigestion
Vumerity (diroximel fumarate) By mouth twice daily Flushing, redness, itching, rash, nausea, vomiting, diarrhea, stomach pain, and indigestion
Bafiertam (monomethyl fumarate) By mouth twice daily Flushing, redness, itching, rash, nausea, vomiting, diarrhea, stomach pain, and indigestion
Aubagio (teriflunomide) By mouth once daily Headache, diarrhea, nausea, hair thinning or loss, and abnormal liver blood tests
Mavenclad (cladribine) By mouth in two yearly treatment courses Upper respiratory infection, headache, and low white blood cell counts

Infused DMTs

Infused DMTs are given through a needle placed in your vein at a healthcare facility,such as a doctor's office, hospital, or infusion center.

Lemtrada

Lemtrada (alemtuzumab) is a monoclonal antibody that targets a protein on the surface of immune system cells called CD52. Lemtrada is approved to treat relapsing-remitting MS and active secondary progressive disease in adults.

Due to safety concerns, the FDA recommends this drug be reserved for patients who do not respond to two or more other DMTs.

How It's Taken

Intravenous infusion of Lemtrada is done over two or more treatment courses. You will receive the drug for five days in a row for the first treatment course and then for three days in a row about one year later.

Side Effects

Lemtrada carries numerous potential side effects.

Common ones include:

  • Skin: Rash, hives, itching, sudden redness in the face, neck, or chest
  • Ears/nose/throat: Swelling of your nose and throat (nasopharyngitis), sinusitis, mouth sores, and sore throat
  • Gastrointestinal: Nausea, vomiting, diarrhea, and stomach pain
  • Musculoskeletal: Pain in your arms/legs/back/joints
  • Neurological: Headache, tingling sensations, and dizziness
  • Endocrine: Thyroid problems
  • General/Infection: Fever, feeling tired, trouble sleeping, urinary tract infection (UTI) upper respiratory tract infection, fungal infection, and herpes viral infection

Potential serious side effects of Lemtrada include:

  • Serious autoimmune problems including immune thrombocytopenic purpura (ITP) in which the body attacks the platelets (blood clotting cells), and kidney problems
  • Serious infusion reactions
  • Stroke (interrupted blood flow to the brain) and tears in the arteries that provide blood flow to your brain (carotid and vertebral arteries)
  • Increased risk of certain cancers
  • Hyperthyroidism (overactive thyroid) and hypothyroidism (underactive thyroid)
  • Low blood cell counts
  • Liver inflammation
  • Overactivity of the immune system that is possibly fatal (hemophagocytic lymphohistiocytosis)
  • Thrombotic thrombocytopenic purpura (TTP) in which platelets clump and block blood vessels
  • Bleeding disorders
  • Serious infections (e.g., PML, tuberculosis, listeria)
  • Inflammation of the gallbladder without gallstones (acalculous cholecystitis)
  • Inflammation of lung tissue (pneumonitis)

Novantrone

Novantrone (mitoxantrone) belongs to a class of drugs called antineoplastics (anti-cancer/chemotherapy). In MS, it works by reducing the activity of T cells, B cells, and macrophages so they cannot attack myelin (the coating around nerve fibers).

Novantrone is approved to treat secondary progressive MS, progressive-relapsing MS, and worsening relapsing-remitting MS in adults.

How It's Taken

Novantrone is infused every three months. Of note, there is a lifetime total allowed dose limit of around 10 doses over two to three years.

Side Effects

The most common side effects of Novantrone are:

  • Nausea
  • Hair loss
  • Menstrual changes
  • Upper respiratory infections and urinary tract infections
  • Mouth sores
  • Irregular heartbeat
  • Diarrhea
  • Constipation
  • Back pain
  • Sinusitis
  • Headache
  • Blue-green urine

Potential serious side effects include:

Tysabri

Tysabri (natalizumab) is a monoclonal antibody that helps prevent potentially harmful immune system cells from crossing the blood-brain barrier into the central nervous system. Tysabri is approved for the treatment of relapsing forms of MS in adults.

How It's Taken

Tysabri is infused once every four weeks.

Side Effects

The most common side effects of Tysabri are:

  • Headache
  • Feeling tired
  • Urinary tract/lung/nose and throat infections
  • Depression
  • Pain in your joint/arms/legs
  • Diarrhea, nausea, and/or stomach-area pain
  • Vaginitis
  • Rash

Possible serious side effects include PML, herpes infections, liver damage, allergic reactions, weakened immune system and higher risk of infections, and low platelet counts.

Ocrevus

Ocrevus (ocrelizumab) is a monoclonal antibody that targets a specific type of white blood cell—CD20 positive B lymphocytes. Ocrevus is approved to treat relapsing forms of MS in adults and also approved to treat primary progressive MS (PPMS) in adults.

How It's Taken

Ocrevus is infused once every six months.

Side Effects

The most common side effects of Ocrevus for those with relapsing MS are upper respiratory tract infections and infusion reactions.

The most common side effects of Ocrevus for those with PPMS are upper respiratory tract infections, infusion reactions, skin infections, and lower respiratory infections.

Potential serious side effects include severe infusion reactions, infections (e.g., herpes viral, PML, and reactivation of hepatitis B), weakened immune system, and risk of cancer, including breast cancer.

Summary of Infused DMTs
 DMT  How It's Taken  Common Side Effects
Lemtrada (alemtuzumab) Infused for five days in a row for the first treatment course and then for three days in a row about one year later Hives, itching, sudden redness in the face, neck, or chest, mouth sores, nausea, pain in your arms/legs/back/joints, headache, tingling sensations, dizziness, thyroid problems, urinary tract infection, and fungal infection, plus more common side effects, as stated
Novantrone (mitoxantrone) Infused every three months  Nausea, hair loss, menstrual changes upper respiratory infections, urinary tract infections, mouth sores, irregular heartbeat, diarrhea, constipation, back pain, sinusitis, headache, and blue-green urine
Tysabri (natalizumab) Infused once every four weeks Headache, feeling tired, urinary tract/lung/nose and throat infections, depression, pain in your joint/arms/legs, diarrhea, nausea, stomach-area pain, vaginitis, and rash
Ocrevus (ocrelizumab) Infused once every six months Relapsing MS: Upper respiratory tract infections and infusion reactions PPMS: Upper respiratory tract infections, infusion reactions, skin infections, and lower respiratory infections

Summary

Disease-modifying therapies for multiple sclerosis are medications taken to slow the progression of the condition and delay disability. These medications come in different forms that may be taken orally, injected, or infused. They are indicated for adults with relapsing forms of MS.

A Word From Verywell

In the end, starting and sticking to a DMT—even if you have to change drugs along the way—is your best bet for delaying disability and preventing irreversible damage to your central nervous system. That said, navigating the ins and outs of all the DMT options is overwhelming for most.

Besides easing stress, the information provided offers a good starting point for discussion when meeting with your neurologist.

Frequently Asked Questions

  • When should you start a DMT?

    The American Academy of Neurology recommends considering a DMT if you have clinically isolated syndrome and two or more brain MRI lesions, or if you have relapsing MS and recent relapses or evidence of MRI activity.

  • How fast will my MS progress while using a DMT?

    DMTs slow disease progression. That said, the course of MS varies from person to person. There is no way to definitively predict how fast someone's MS will progress.

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Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read our editorial process to learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.
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