Comprehensive Management of Multiple Sclerosis: The Vital Role of Pharmacists

Multiple sclerosis (MS) is the most common demyelinating disease of the central nervous system (CNS) that is immune-mediated. It affects approximately 400,000 individuals in the United States and 2.5 million worldwide.¹ MS is characterized by episodes of CNS dysfunction that are clinically distinct (ie, clear beginning with worsening followed by at least partial resolution). While the average age of onset is between 20 to 40 years, the disease can present at any age with nearly 10% of cases presenting before age 18 years.² Common symptoms of MS include visual disturbances, ataxia, fatigue, thinking and/or memory difficulties, and emotional distress.¹ Table 1 describes the unique subtypes of MS.^3,5,6

Managing MS

Overall treatment goals include modifying the course of the disease, decreasing disability, and improving quality of life.Treating MS includes 3 sub-categories: treating exacerbations, disease-modifying therapies, and treating symptoms. Symptom management in MS is targeted towards addressing patient specific symptoms and includes corticosteroids, muscle relaxants, antidepressants, and anticonvulsants. Comprehensive treatment can also include lifestyle modifications, cognitive behavioral therapy (CBT) and physical therapy to improve the patient’s overall quality of life. Regular monitoring is required to assess treatment efficacy, tolerability, and disease progression.

Overall treatment goals include modifying the course of the disease, decreasing disability, and improving quality of life.Treating MS includes 3 sub-categories: treating exacerbations, disease-modifying therapies, and treating symptoms. Image Credit: © Minerva Studio - stock.adobe.com

Treating Exacerbations

Decreasing the length and/or severity of an exacerbation is important to patients as these affect their quality of life. The most used medication for this is high dose steroids, such as intravenous methylprednisolone, given over several days to reduce inflammation and suppress the immune response. Exacerbation symptom management can also include muscle relaxants, pain management, and physical therapy. Exacerbation treatment requires close monitoring to assess patient’s treatment response.

Disease-Modifying Therapies (DMTs)

The goal of disease-modifying therapies (DMTs)is to change the course of MS and decrease the progressive disability that can occur.⁴ Based on the American Association of Neurology’s treatment guidelines, choosing to start, continue, change, or discontinue a DMT requires a patient-centered discussion between the neurologist and patient that includes discussions of adverse events.⁵ These medications are distributed through specialty pharmacies only and have annual costs up to $100,000 annually, which limits access for some patients.6 Additionally, these medications can require nursing and other infusion-related costs. The first-generation agents include interferon-b1a (Avonex; Biogen Idec and Rebif; EMD Serono, Inc), interferon-b1b (Betaseron; Bayer HealthCare Pharmaceuticals and Extavia; Novartis), pegylated interferon-b1a (Plegridy; Biogen Inc), glatiramer acetate (Copaxone; Teva Pharmaceuticals and Glatopa; Sandoz Inc), and mitoxantrone (Novantrone; Amgen). Many of the secondary generation agents are oral, including fingolimod (Gilenya; Novartis), siponimod (Mayzent; Novartis International AG), ozanimod (Zeposia; Bristol Myers Squibb), ponesimod (Ponvory; Janssen Pharmaceuticals, Inc), dimethyl fumarate (Tecfidera; Biogen Inc), diroximel fumarate (Vumerity; Biogen Inc), monomethyl fumarate (Bafiertam; Banner Life Sciences), teriflunomide (Aubagio; Sanofi Genzyme), and cladribine (Mavenclad; Merck). There are 3 second-generation agents that are IV infusions administered in a health care setting: natalizumab (Tysabri; Biogen Idec Inc), alemtuzumab (Lemtrada; Sanofi), and ocrelizumab (Ocrevus; Genentech). Finally, there is 1 self-injectable second generation DMT: ofatumumab (Kesimpta; Novartis).

Treating Symptoms

According to recent studies, patients with MS are 2 to 3 times more likely to experience depression compared to the general population.7 These mental health challenges include difficulties with memory, attention, and processing speed. Cognitive impairments, along with physical limitations, pain, and the unpredictability of MS make it essential for a patients’ care team to routinely assess their quality of life.⁸ Pharmacists can offer resources and guidance for patients to receive mental health support. Mindfulness-based interventions (MBI), such as meditation, yoga, and/or music therapy, can be helpful mental health tools for patients living with MS.7 These resources include support groups, telehealth services, lifestyle/wellness programs, and educational materials. While effective, these treatments can add to a patient’s economic burden.

While DMT’s are important for a reduction in worsening of the disease process, patients are most concerned with the debilitating symptoms that accompany the disease. As shown in Table 2, many medications are available to treat depression and other symptoms of MS, which allows pharmacists to intervene and improve the quality of life for these patients.⁴

Additional Considerations - Vaccines

Another area for pharmacists to make a positive impact is ensuring these patients are up to date on their vaccines. Individuals with MS, especially if on a DMT, are immunocompromised, which puts them at higher risk for infection. The CDC recommends the following vaccines for immunocompromised individuals: COVID-19; influenza; tetanus, diptheria, pertussis (Tdap or Td); zoster; and pneumococcal.9 The following vaccines are recommended for some immunocompromised individuals based on either age or risk for severe outcomes from the disease: human papillomavirus, hepatitis B, and monkey pox.⁹

Conclusion

Online platforms such as the National Multiple Sclerosis Society and organizations like the American Pharmacists Association are useful resources for staying informed about new and upcoming treatments. The Multiple Sclerosis Foundation provides resources, educational materials, and networking opportunities to stay informed about advancements in MS treatment.

The role of the pharmacist in the care and management of individuals with MS is indispensable and necessary. Pharmacists can help by providing medication therapy management, compassionate support, patient education, and collaboration with the patient care team. Pharmacists serve as trusted allies for their patients and, with adequate knowledge about their patient’s condition and treatment, they can effectively help to improve their patients’ quality of life.

Disclosure: No funding was provided for this paper.

About the Authors

Destiny McCrary is a 2025 PharmD candidate at the Auburn University Harrison College of Pharmacy.

Rebecca Maxson, PharmD, BCPS, is an associate clinical professor at the Department of Pharmacy Practice in the Auburn University Harrison College of Pharmacy.

References

1. Ghasemi N, Razavi S, Nikzad E. Multiple Sclerosis: Pathogenesis, Symptoms, Diagnoses and Cell-Based Therapy. Cell J. 2017;19(1):1-10. doi:10.22074/cellj.2016.4867.
2. Dilokthornsakul P, Valuck RJ, Nair KV, Corboy JR, Allen RR, Campbell JD. Multiple sclerosis prevalence in the United States commercially insured population. Neurology. 2016;86(11):1014-21. doi:10.1212/WNL.0000000000002469.
3. Tafti D, Ehsan M, Xixis KL. Multiple Sclerosis. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Accessed April 11, 2024. https://www/ncbi/nlm.nih.gov/books/NBK499849/
4. Bainbridge JL, Miravalle A, Wong P, et al.Multiple Sclerosis.In:DiPiro JT, Yee GC, Haines ST, Nolin TD, Ellingrod VL, Posey L. eds.DiPiro’s Pharmacotherapy:A Pathophysiologic Approach, 12th Edition. McGraw Hill; 2023. Accessed April 22, 2024.https://accesspharmacy.mhmedical.com/content.aspx?bookid=30997&sectionid=267040700.
5. Rae-Grant A, Day GS, Marrie RA, et al.Practice guideline recommendations summary: disease-modifying therapies for adults with multiple sclerosis.Neurology. 2018;90:777-788. doi:10.1212/WNL.0000000000005347.
6. Davis BE, Lakin L, Binns CC, Currie KM, Rensel MR. Patient and Provider Insights into the Impact of Multiple Sclerosis on Mental Health: A Narrative Review. Neurol Ther. 2021;10(1):99-119. doi:10.1007/s40120-021-00240
7. Hosseini Z, Homayuni A, Etemadifar M. Barriers to quality of life in patients with multiple sclerosis: a qualitative study. BMC Neurol 2022;22:174. doi:10.1186/s12883-022-02700-7
8. Hartung DM. Health economics of disease-modifying therapy for multiple sclerosis in the United States. Ther Adv Neurol Disord. 2021;17:14:1756286420987031. doi:10.1177/1756286420987031
9. Adult immunization schedule by age. CDC. Updated February 29, 2024. Accessed April 11, 2024. https://www.cdc.gov/vaccines/schedules/hcp/imz/adult.html