Disease Modifying Agents

National recommended practice guidelines advocate early immunomodulating treatment to slow disease progression and help prevent irreversible neurological damage. Pharmacological management of this complex disease also involves treating acute attacks, managing symptoms, and monitoring interactions among medications, and between the disease process and the medical therapy.

The National MS Society Medical Advisory Board supports early intervention with disease modifying drugs to prevent relapses. Studies show that early relapses can cause permanent axonal damage and destruction of myelin. The Medical Advisory Board recommends that therapy with a disease-modifying drug should be started as soon as a diagnosis of relapsing-remitting MS is made, and that therapy should be continued indefinitely unless there is a clear lack of benefit, intolerable side effects, or until a better therapy is found.


Oral Administration


Mechanism of Action


Adverse reactions



Induction of nuclear factor 2 (Nrf2), the primary cellular defense against the cytotoxic effects of oxidative stress?

Hypersensitivity to dimethyl fumurate

Progressive multifocal leukoencephalopathy

Hepatic disease
Breast feeding

Leukopenia, leukoencephalopathy, angioedema, anaphylactoid reactions, eosinaphilia, elevated hepatic enzymes, ABD pain, DNV, rash, pruritus



Pyrimidine synthesis inhibitor that reduces proliferation of peripheral T&B cells, reducing the concentration of activated lymphocytes in the CNS as well as reduced inflammatory phosphlipid synthesis?

Hypersensitivity to teriflunomide,
Alcoholism, hepatic disease, immunosupression.
agranulocytosis, chemotherapy, infection, thrombocytopenia, tuberculosis, vaccination with live vaccines, eosinophilic pneumonia, pneumonitis, pulmonary disease, pulmonary fibrosis, sarcoidosis.
Hypertention, diabetes mellitus
Reproductive risk (Male & Female)
Breast feeding.

Renal failure, hepatic failure, pancytopenia , Stevens-Johnson syndrome, erythema multiforme, anaphylactoid reactions, hyperkalemia, myocardial infarction, pancreatiti, pulmonary fibrosis, eosinophilic pneumonia, fetal death, teratogenesis



Inhibits lymphocyte release from the lymph nodes, decreasing the number of lymphocytes available to migrate to the CNS.

Hypersensitivity to fingolimod, Recent or current MI, stroke, heart failure

Headache, myalgia, diarrhea, back pain, abnormal liver tests, and cough. Rarely: death or bradyarrhythmia and atrioventricular block at treatment initiation, infections, macular edema, respiratory effects, hepatic effects, and fetal risk



Interferes with DNA synthesis and repair by incorporation into DNA, resulting in sustained reduction of circulating T and B lymphocytes implicated in the pathogenesis of MS

Current malignancy, pregnant women and persons of reproductive potential, HIV, chronic infections (eg, hepatitis, tuberculosis).

Upper respiratory infection, headache, low white blood cell count



Inhibits lymphocyte release from the lymph nodes, decreasing the number of lymphocytes available to infiltrate CNS.

CYP2C9*3/*3 genotype increases cardiovascular risk.  Verify vaccination status, increased infection risk.

 Headache, hypertension, and transaminase elevation; macular edema

Injectable Treatment

Generic/Brand Mechanism of Action Contraindications Adverse reactions

peginterferon beta-1a


Promotes oligodendrocyte survival, differentiation and axonal recovery by suppressing T-cells associated demyelination and inhibits pro-inflammatory cytokines. Promotes formation of anti-inflammatory cytokines. Inhibits T-cell migration across the blood-brain barrier?


Hypersensitivity to natural or recombinant interferon beta or peginterferon
Alcoholism, hepatic disease, hepatitis, jaundice
Depression, psychosis, suicidal ideation
Seizure disorder
Angina, cardiac arrhythmias, cardiac disease, heart failure, myocardial infarction
Bone marrow suppression, autoimmune disease, thyroid disease
Pregnancy, breast feeding
Hemolytic-uremic syndrome, thrombotic thrombocytopenic purpura

Injection site reactions
Influenzalike illness

interferon beta-1a


Albumin hypersensitivity, latex hypersensity, hamster protein hypersensitivity
Latex hyperse

Liver failure, cardiac failure
Flu-like symptoms

interferon beta-1a


Pregnancy, heart failure, albumin or latex hypersensitivity, breast feeding, depression, immunosuppression,

Liver failure, cardiac failure
Flu-like symptoms

glatiramer acetate


Affects antigen-presenting cells such as monocytes and dendritic cells causing alteration in cytokine secretion by CD4+ and CD8+ T-cells?

Mannitol hypersensitivity, immunosuppression, infection, pregnancy, breast feeding

Adverse reactions include injection site reactions, vasodilatation, chest pain, asthenia, infection, pain, nausea, arthralgia, anxiety, and hypertonia.

Intravenous Infusion


Mechanism of Action

Adverse reactions



Natalizumab is a monoclonal antibody thought to reduce demyelination by interferring with adhesion molecules that facilitate migration T-lymphocytes across the blood brain barrier.

Progressive multifocal leukoencephalopathy, hypersensitivity, HIV, immunosupression, organ transplant, infection, leukemia

Headache, fatigue, arthralgia, urinary tract infection, lower respiratory tract infection, gastroenteritis, vaginitis, depression, pain in extremity, abdominal discomfort, diarrhea, rash



Monoclonal antibody that inhibits replication of the CD20-positive B lymphocyte cell lines, that damage nerve cells and the myelin sheaths

Active hepatitis B virus infection, serious infusion reaction.

Pruritus, rash, urticaria, erythema, bronchospasm, throat irritation, oropharyngeal pain, dyspnea, pharyngeal or laryngeal edema, flushing, hypotension, pyrexia, fatigue, headache, dizziness, nausea, and tachycardia.



Antineoplastic DNA-reactive agent that intercalates into deoxyribonucleic acid (DNA) forming crosslinks and strand breaks. It also interferes with ribonucleic acid (RNA) and is a potent inhibitor of topoisomerase II, an enzyme responsible for uncoiling and repairing damaged DNA.

Preexisting cardiac disease, myelosuppression, hepatic disease, pregnancy, breast feeding.

Neutropenia, GI bleeding renal failure, heart failure, seizures, new primary malignancy, pulmonary edema anaphylactoid reactions, intracranial bleeding, pancytopenia, cardiomyopathy, tissue necrosis




  Monoclonal antibody that binds to CD52 on T and B lymphocytes. Binding causes lysis of the  lymphocytes reducing T-cells infiltration to the CNS.

Active tuberculosis, inactive tuberculosis, Listeria monocytogenes infection, HIV, shingles, herpes simplex infection, chronic hepatitis B, Chronic Hepatitis C, protozoa infection.

Immune thrombocytopenia, autoimmunity, infusion reactions, thyroid disorders, malignancies, glomerular nephropathies, etc.



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Early use of disease-modifying drugs can slow disease progression and prevent MS relapses.


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