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Practice Therapeutics

Disease-modifying therapies for multiple sclerosis

BMJ 2018; 363 doi: (Published 27 November 2018) Cite this as: BMJ 2018;363:k4674
  1. Floriana De Angelis, clinical research associate1,
  2. Nevin A John, clinical research associate1,
  3. Wallace J Brownlee, clinical research fellow and locum consultant neurologist1 2
  1. 1Queen Square MS Centre, Department of Neuroinflammation, UCL Queen Square Institute of Neurology, London, UK
  2. 2National Hospital for Neurology and Neurosurgery, Queen Square, London, UK
  3. Correspondence to: F De Angelis
  4. This is one of a series of occasional articles on therapeutics for common or serious conditions, covering new drugs and old drugs with important new indications or concerns. The series advisers are Robin Ferner, honorary professor of clinical pharmacology, University of Birmingham and Birmingham City Hospital, and Patricia McGettigan, clinical senior lecturer in clinical pharmacology, Queen Mary's University, London. To suggest a topic, please email us at

What you need to know

  • Disease-modifying therapies (DMTs) early in the course of active relapsing multiple sclerosis can prevent relapses, new brain and spinal cord lesions, and worsening neurological disability

  • Some DMTs are associated with potentially serious adverse reactions, and careful monitoring is required, usually through a specialist multiple sclerosis clinic

  • Newer DMTs have better short term outcomes than older DMTs, but there are insufficient data about their long term effectiveness and harms

A 32 year old woman with multiple sclerosis presented to her general practitioner with a five day history of numbness and weakness in the right leg. She felt well in herself and did not describe any symptoms to suggest an intercurrent infection. She had been taking weekly intramuscular injections of interferon beta-1a for the previous 18 months and reported flu-like symptoms that could last for up to 24 hours after each dose. She asked if there was a need to change her treatment and what alternatives were available.

Multiple sclerosis is a chronic, immune-mediated, demyelinating disorder of the central nervous system affecting over two million people worldwide.1 It is a major cause of physical disability in young adults and can have profound implications for cognition, emotional wellbeing, and employment. Patients commonly present with unilateral visual loss (due to optic neuritis), double vision, sensory symptoms, limb weakness, or imbalance.2 The diagnosis is based on clinical features and findings on magnetic resonance imaging (MRI), sometimes supported by lumbar puncture and other investigations.23

Nearly 80-85% of people with multiple sclerosis experience a relapsing course: episodes (attacks or relapses) of new or worsening neurological symptoms lasting at least 24 hours, followed by full or partial recovery, in the absence of fever or infection (fig 1).3 If left untreated, most people with relapsing multiple sclerosis develop disability over time. This can …

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