MS Disease Modifying Therapies
There has been significant progress in the development of disease modifying therapies (DMT’s) in the past two decades and there are currently many options available. For those that meet criteria there are a number of funded DMT’s that are available in the New Zealand health system. Deciding if and when to start a DMT is a shared decision between you and your neurologist, based on your specific needs and circumstances. To access funded DMT’s for the treatment of MS, your neurologist will assess you and make and application for funding. If granted each application is valid for 12 months, your GP or neurologist must apply for the funding to be renewed each year.
Disease‑Modifying Therapies (DMTs) are treatments that target the immune system with the goal of reducing relapse frequency and slowing disability progression in MS. While not curative, they offer a proven way to protect your brain and spinal cord from further damage.
Currently in New Zealand we have 8 DMTs available for people with relapsing remitting MS (RRMS), and one DMT for people with primary progressive MS (PPMS).
Disease Modifying Therapies for RRMS
Tysabri® (Natalizumab)
The active ingredient of Tysabri® is natalizumab. Natalizumab is a synthetic antibody which locks onto certain immune cells, called T-cells. Once the natalizumab is attached to the T- Cells, they cannot cross the blood brain barrier to attack the myelin or nerves in the brain and spinal cord where inflammation and damage is caused in MS.
How is Tysabri administered?
Tysabri is administered by intravenous (IV) infusion once every twenty-eight days. You might be prescribed it 4 or 6 weekly depending on your circumstances and your neurologists usual practice.
In the majority of cases this will be given in an infusion clinic attached to a hospital. A nurse or other qualified health professional will monitor you before, during and after your infusion.
Potential side-effects
Most people taking Tysabri tolerate it well, but there can be side effects.
Common side effects include fever, joint pain, tiredness, a runny or blocked nose, sore throat, feeling or being sick, headaches or dizziness.
During the infusion of Tysabri, and up to an hour afterwards, some people shiver, or feel sick or dizzy. Around one in 25 people who take Tysabri may have an allergic reaction to taking it, either during the infusion or in the hour following. In addition, some people might have skin reactions to the infusion.
One serious potential side effect is PML (progressive multifocal leukoencephalopathy), a viral infection in the brain. It can cause severe neurological symptoms, which may at first be mistaken for MS relapses. Meticulous monitoring for this rare side effect is a requirement mandated by PHARMAC before and during the on-going course of treatment.
Monitoring includes specialised blood tests and regular MRI scans. All nurses are trained in administration of the drug and infusions occur under the supervision of a neurologist or a physician experienced in neurological conditions.
Neurologists prescribing Tysabri must ensure that everyone – professionals and patients – is aware of the risks, the early signs of PML to look out for and what to do if they notice these signs.
Ocrevus® (Ocrelizumab)
Ocrevus is a humanised monoclonal antibody designed to selectively target CD20-positive B cells, a specific type of immune cell thought to be a key contributor to damage to myelin (which insulates the nerves and speeds nerve signals) and axons (part of the nerve cell). Based on preclinical studies, Ocrevus binds to CD20 cell surface proteins expressed on certain B cells, but not on stem cells or plasma cells, and therefore it doesn’t compromise important functions of the immune system.
How is Ocrelizumab Administered?
Ocrevus is administered by two intravenous (IV) infusions in the first six months, then one every six months after that. The first and second infusions are done two weeks apart.
Pre-medications are taken 30-60 mins before infusion. Infusion takes between 2 and 3 and a half hours. You would then be observed for at least one hour after the infusion.
Possible side effects
The most common side effects people experience are mild to moderate infusion reactions and upper respiratory tract infections.
Ocrelizumab can increase your risk of infections and some cancers. While on the treatment you will be advised to maintain usual health screening and infection prevention measures.
Progressive multifocal leukoencephalopathy (PML), a rare and potentially fatal viral brain disease, occurs only very rarely in patients treated with Ocrelizumab.
Gilenya® (Fingolimod)
Gilenya is a treatment for relapsing-remitting MS which stops lymphocytes from contributing to an immune reaction.
How is Gilenya administered?
Gilenya is taken in capsule form once a day. The first dose of Gilenya is given in a clinic that has been set up and trained to administer the treatment, and patients are observed for six hours afterwards in case they have any side effects. Following that first dose, patients take one capsule each day at home.
Possible side effects
Gilenya is generally well-tolerated, although some people may experience side effects, some of them potentially quite serious. About one in ten people experience each of the following side effects: headaches, diarrhoea, back pain, coughing and dizziness.
When you first take Gilenya it can cause your heart rate to slow down or become irregular. This can make you feel dizzy or tired. Because of the risk of cardiac problems, patients are monitored carefully for cardiac symptoms for six hours after their first dose.
Gilenya also lowers the numbers of white blood cells in your blood. As white blood cells fight infection, you may find that you pick up illnesses and infections more easily while taking Gilenya.
Very rarely, Gilenya can cause a problem with your vision, known as macular oedema. People taking this medication will routinely require several other screening tests, including a specialised eye test, Ocular Coherence Tomography (OCT).
Tecfidera® (dimethyl fumarate)
The active ingredient in Tecfidera® is dimethyl fumarate, which works to reduce MS relapses and slow the progression of RRMS. Tecfidera reduces the inflammation in the brain caused by MS and helps to protect the cells that form the myelin against attacks which may damage it.
It is thought that Tecfidera does this by turning on an antioxidant mechanism in the body which deactivates and removes free radicals (generated by inflammation) that are damaging the myelin.
Tecfidera cannot repair damage that has already been caused by MS. When you start Tecfidera you might not notice an improvement, but Tecfidera may still be working to help prevent your MS from becoming worse.
How is Tecfidera administered?
Tecfidera comes in a capsule that is taken twice a day; one capsule in the morning and the second capsule in the evening.
The starting dose is one 120mg capsule, twice a day for 7 days. After the first 7 days a regular dose of one 240mg capsule is taken twice a day. It is important to take as prescribed by your doctor, to take whole and with a glass of water.
Possible side effects
Side effects from tecfidera can include:
- reddening of the face or body feeling warm, hot, burning, or itchy (flushing)
- gastrointestinal symptoms (nausea, vomiting, diarrhoea, indigestion, stomach pain/cramps)
- inflammation of the lining of the intestines (gastroenteritis)
- burning sensations
- itchy skin
- rashes
- pink or red blotches on the skin
The above list includes the more common side effects of tecfidera. If any of these persist or worsen, talk to your doctor as they may also be due to an infection or allergic reaction.
Aubagio® (teriflunomide)
Like Gilenya, Aubagio works by selectively interfering with the ability of white blood cells (lymphocytes) to produce the disease response and nerve damage that ultimately leads to relapses.
How is Aubagio administered?
Aubagio is available in tablet form in two strengths: 7mg and 14mg. Your GP or neurologist will recommend the appropriate dosage. Tablets are taken once daily with or without food. It should be taken at the same time each day with a glass of water.
Possible side effects
Side effects from Aubagio can include diarrhoea, rashes or itchy skin, hair loss, weight loss, fatigue or weakness and numbness or tingling of the hands or feet. If you experience any of these while taking Aubagio to a point where they worry you, you should talk to your GP or neurologist.
Some important considerations for taking Aubagio
Aubagio shouldn’t be taken if you’re pregnant or breastfeeding. If you’re a woman of childbearing age, it’s important to use safe and reliable contraception while taking Aubagio. If you wish to have children, whether you’re a man or a woman, you should speak to your doctor about this if you’re taking or planning to take Aubagio.
You should also tell your GP or neurologist if you have any allergies, and if you have any other medical issues, like high blood pressure, liver problems, tuberculosis, kidney disease, chronic or serious infections, a decreased white blood cell count or an illness that lowers your body’s resistance to disease. You should also make them aware of any other medicines, herbal supplements or vitamin supplements you are taking or plan to take.
Copaxone® (glatiramer acetate)
Copaxone® (glatiramer acetate) is a disease-modifying treatment for relapsing-remitting MS. It is a synthetic compound made up of four amino acids (the building blocks of protein) that are found in myelin. Copaxone acts as a “decoy”, attracting the immune system cells to itself rather than to myelin. It also makes some T-cells less active against myelin.
How is Copaxone administered?
Copaxone is administered as a daily injection. Your health professional will advise how to do the injections and offer advice where required.
Possible side effects
The most common side effects include injection site reactions such as lipoatrophy (which involves a permanent indentation in the skin), itching, swelling, redness and sometimes pain at the site.
Some people also experience a post-injection reaction involving shortness of breath, flushing, and chest tightening. This usually subsides by itself after 15-30 minutes without further intervention or long-term problems. If symptoms last longer than 30 minutes, it is recommended that you contact your health professional immediately or go straight to your nearest hospital.
Other potential side effects include headaches, depression, anxiety, nausea, feeling weak, chest pain, pain, swollen lymph nodes and gastrointestinal changes. Less common side effects include blood cell changes, extra heartbeats, thyroid changes, dilation of blood vessels and immediate post-injection reaction (IPIR).
Interferons
Interferons are a group of proteins that are normally produced by cells in the immune system in response to viral infection and other foreign bodies and conditions. Interferons were named for their ability to interfere with viruses that are replicating themselves in the body.
One type of interferon (beta) has a variety of effects on the immune system, including a reduction in those immune responses directed at the myelin. There are two forms of interferon beta: interferon beta 1a (Avonex®) and interferon beta 1b (Betaferon®).
How is Avonex administered?
Avonex is a weekly intramuscular (directly into the muscle) injection.
Before starting Avonex, you should have blood tests to measure blood cell counts and check liver function. You should have regular blood tests to monitor blood cell counts and liver function every three months for the first year, then less frequently. Your neurologist will advise whether this should be done within the hospital clinic or through your local GP practice.
How is Betaferon administered?
Betaferon is self-administered every other day as a subcutaneous (under the skin) injection.
Your MS nurse will show you how to do the injections as well as giving advice and on-going training and support should you need it. For some patients Betaferon is initially started on a lower dose. Your specialist will advise the recommended dosage for you.
Important considerations for taking an interferon
You should tell your doctor if:
- you have a history of or experience severe depression or suicidal thoughts
- you become pregnant or wish to have children. This includes men whose partner plans to become pregnant
- you have any health problems or are taking other medicines
- you have any allergies or experience an allergic reaction
Possible side effects
The most common side effects are flu-like symptoms, which may include headache, muscle ache and stiffness, chills or fever following an injection, injection site reactions, injection site fatigue with prolonged use, blood cell abnormalities, weakness or tiredness, difficulty sleeping, diarrhoea, nausea and vomiting, muscular or joint pain and infections.
You are more likely to have these side effects when you first start taking an interferon and they should subside over time. Speak to your health professional to discuss ways to reduce the side effects.
Less common side effects can include changes in menstruation (periods), neurological symptoms, mood changes, depression, liver abnormalities, allergic reactions, heart problems and hypertension, hair thinning or loss, damage to small blood vessels leading to kidney problems.
Disease Modifying Therapies for PPMS
Ocrevus® (Ocrelizumab)
Ocrevus is a humanised monoclonal antibody designed to selectively target CD20-positive B cells, a specific type of immune cell thought to be a key contributor to damage to myelin (which insulates the nerves and speeds nerve signals) and axons (part of the nerve cell). Based on preclinical studies, Ocrevus binds to CD20 cell surface proteins expressed on certain B cells, but not on stem cells or plasma cells, and therefore it doesn’t compromise important functions of the immune system.
How is Ocrelizumab Administered?
Ocrevus is administered by two intravenous (IV) infusions in the first six months, then one every six months after that. The first and second infusions are done two weeks apart.
Pre-medications are taken 30-60 mins before infusion. Infusion takes between 2 and 3 and a half hours. You would then be observed for at least one hour after the infusion.
Possible side effects
The most common side effects people experience are mild to moderate infusion reactions and upper respiratory tract infections.
Ocrelizumab can increase your risk of infections and some cancers. While on the treatment you will be advised to maintain usual health screening and infection prevention measures.
Progressive multifocal leukoencephalopathy (PML), a rare and potentially fatal viral brain disease, occurs only very rarely in patients treated with Ocrelizumab.
Who Qualifies for Funded Treatment?
Your neurologist or GP will help you work through the special authority criteria, which are complex and best discussed alongside your clinical team. Generally, to be eligible for funded DMTs, you must:
- Have a confirmed diagnosis of MS (meeting the McDonald 2017 criteria, confirmed by a neurologist)
- Have an Expanded Disability Status Scale (EDSS) score between 0 and 6.0 (able to walk 100 metres without rest or assistance, using a cane/crutch/brace if needed)
- Had at least one significant relapse in the past 12 months (or two in the previous 24 months), confirmed by your GP or neurologist
- Have evidence of disease activity, often shown by new changes on an MRI scan
Renewals: Your GP or neurologist must reapply every year, confirming your continued eligibility—primarily that you can walk 100 metres or more without rest or assistance.
Unfunded and Emerging Treatments
- Mavenclad (cladribine): Approved but not funded; more information from your neurologist.
- Stem Cell Transplant (aHSCT): Currently not available for MS in NZ, though advocacy is strong for its introduction for those who do not respond to conventional treatments. Overseas treatment is possible but self-funded.
Making Treatment Decisions
Treatment discussions are encouraged early in a person’s diagnosis. This can often be overwhelming due to the range of options and because it comes soon after a diagnosis is made. Ideally the decision making should be shared between you and the MS care team, so the choices made are the best ones for you.
Your MS care team has the expertise to guide and support you through this process, you can also reach out to your local MS society for support.
Other Medicines & Symptom Management
For the latest updates and support, kōrero with your doctor or MS Society. He waka eke noa – we’re all in this together.