What’s the Difference Between Oral, Injectable, and Infusable MS Treatments?

What are disease-modifying therapies (DMT)?

Disease-modifying therapies (DMTs) are designed to slow the long-term progression of the disease, reduce relapses, and prevent new damage from occurring.

Depending on the specific medication and its form, DMTs may be given orally, by injection, or by infusion.

While many injectable DMTs may be self-injected at home, intravenous (IV) and infusion medications must be administered by a healthcare professional in a doctor’s office, clinic, or hospital.

Types of DMTs to treat MS

Oral medications

Oral medications are medications that must be swallowed. Oral medications require the ability to easily swallow. These can be tablets, capsules, or liquids. You may take these at home.

Non-oral medications

Non-oral medications are given directly into your body. These DMTs will be given on a regularly scheduled basis — daily, weekly, monthly, or on another specific schedule. They may be given in several ways:

• Intravenous (in a vein): Intravenous medications may be given through an IV or infused through a port-a-catheter (port), a surgically implanted access point for infused medications. Medications that are injected into a port or intravenously need to be administered at an infusion center or with the assistance of a home nurse.
• Intramuscular (in the muscle): Intramuscular injections are injected directly into a large muscle. You, a friend, or a family member may give you this shot; a nurse may come to your home; or you may need to go to a doctor’s office.
• Subcutaneous (under the skin): Subcutaneous injections are given in the top layers of skin, but not into a muscle. Much like intramuscular injections, these may be self-administered or given by another person.

You and your doctor will discuss the best DMT options for you.

What are self-injectable MS medications?

Self-injectable medications are approved for the long-term treatment of relapsing-remitting MS (RRMS).

A medical professional will train you in the injection process so that you can safely administer your own dose. All medications that are injected subcutaneously or intramuscularly have the potential to cause redness or discoloration, swelling, and pain at the injection site, in addition to their more specific side effects.

Avonex (interferon beta-1a)

• Benefit: works as an immune system modulator
• Dose frequency and method: weekly, intramuscular injection (in a muscle)
• Common side effects include: headache, flu-like symptoms
• Warnings include: liver enzymes and complete blood count (CBC) may need to be monitored

Betaseron (interferon beta-1b)

• Benefit: works as an immune system modulator
• Dose frequency and method: every other day, subcutaneous injection (under the skin)
• Common side effects include: flu-like symptoms, low white blood cell (WBC) count
• Warnings include: liver enzymes and CBC may need to be monitored

Copaxone (glatiramer acetate)

• Benefit: works as an immune system modulator, blocks attack on myelin
• Dose frequency and method: daily or three times per week, subcutaneous injection
• Common side effects include: flushing, shortness of breath, rash, chest pain
• Warnings include: injection sites can become permanently indented because fatty tissue is destroyed (to reduce this side effect, careful rotation of injection sites is recommended)

Extavia (interferon beta-1b)

• Benefit: works as an immune system modulator
• Dose frequency and method: every other day, subcutaneous injection
• Common side effects include: flu-like symptoms, headache
• Warnings include: liver enzymes and CBC may need to be monitored

Glatopa (glatiramer acetate)

• Benefit: works as an immune system modulator, blocks attack on myelin
• Dose frequency and method: subcutaneous injection, 20 milligrams (mg) daily or 40 mg three times per week
• Common side effects include: redness or discoloration, swelling, pain at the injection site
• Warnings include: injection sites can become permanently indented because fatty tissue is destroyed (to reduce this side effect, careful rotation of injection sites is recommended)

Kesimpta (ofatumumab)

• Benefit: depletes some immune B cells that cause nerve damage
• Dose frequency and method: subcutaneous injection weekly for the first 4 weeks, then monthly
• Common side effects include: reactions near the injection site, fever and other flu-like symptoms, upper respiratory tract infection, and headache
• Warnings include: If you need to make an adjustment in your dosing schedule because of a hepatitis B infection or vaccination, you must discuss your new scheduling or adjustment with your doctor.

Plegridy (pegylated interferon beta-1a)

• Benefit: works as an immune system modulator
• Dose frequency and method: every 2 weeks, subcutaneous injection
• Common side effects include: flu-like symptoms
• Warnings include: liver enzymes may need to be monitored

Rebif (interferon beta-1a)

• Benefit: works as an immune system modulator
• Dose frequency and method: three times per week, subcutaneous injection
• Common side effects include: flu-like symptoms
• Warnings include: liver enzymes may need to be monitored

What are IV medications for MS?

Another type of DMT administration option for treating MS is intravenous infusion. Instead of entering your system intramuscularly or subcutaneously, infusions go directly into a vein.

The infusions must be given in a clinical setting by a trained professional. Typically, the doses of IV MS medications aren’t scheduled as often as intramuscular or subcutaneous medications.

Ocrelizumab (Ocrevus) is the only FDA-approved medication for people with primary progressive MS (PPMS) and RRMS.

Lemtrada (alemtuzumab)

• Benefit: suppresses myelin-damaging immune cells
• Dose frequency: daily for 5 days; 1 year later, daily for 3 days
• Common side effects include: nausea, vomiting, diarrhea, headache, rash, itching
• Warnings include: can cause cancer and idiopathic thrombocytopenic purpura (ITP), a bleeding disorder

Mitoxantrone hydrochloride

This medication is only available as a generic drug.

• Benefit: works as an immune system modulator and suppressor
• Dose frequency: once every 3 months (lifetime limit of 8 to 12 infusions over 2 to 3 years)
• Common side effects include: hair loss, nausea, amenorrhea
• Warnings include: can cause heart damage and leukemia; only appropriate for people with severe cases of RRMS due to the high risk of serious side effects

Novantrone (mitoxantrone)

• Benefit: reduces the activity of T cells, B cells, and macrophages that appear to play a key role in damaging the myelin sheath
• Dose frequency: an infusion lasting 5 to 15 minutes every 3 months, with a limit of 8 to 12 infusions over 2 to 3 years
• Common side effects include: allergic reactions, pain and swelling at the injection site, nausea and vomiting, arrhythmia, and other heart problems
• Warnings include: this is a chemotherapy drug that is not suitable for people with heart problems; it may increase the risk of developing acute myeloid leukemia

Ocrevus (ocrelizumab)

• Benefit: targets B cells, which are WBCs that damage nerves
• Dose frequency: 2 weeks apart for the first two doses; every 6 months for all later doses
• Common side effects include: flu-like symptoms, infection
• Warnings include: can cause cancer and, in rare instances, life threatening infusion reactions

Tysabri (natalizumab)

• Benefit: inhibits adhesion molecules, which disrupt the immune system
• Dose frequency: every 4 weeks
• Common side effects include: headache, joint pain, fatigue, depression, abdominal discomfort
• Warnings include: can increase the risk of progressive multifocal leukoencephalopathy (PML), a potentially fatal brain infection

What are the oral MS medications?

If you’re not comfortable with needles, there are oral options for treating MS.

These medications are the easiest to self-administer and require that you maintain a regular dosing schedule. Most are taken once or twice daily.

Aubagio (teriflunomide)

• Benefit: works as an immune system modulator, inhibits nerve degeneration
• Dose frequency: daily
• Common side effects include: headaches, liver changes (such as an enlarged liver or elevated liver enzymes), nausea, hair loss, reduced WBC count
• Warnings include: can cause severe liver injury and birth defects

Bafiertam (monomethyl fumarate)

• Benefit: most likely reduces the inflammation caused by the immune response in MS and may help protect the brain and spinal cord
• Dose frequency: by mouth, one 95-mg capsule twice a day for 7 days, increasing to two capsules daily after 7 days
• Common side effects include: an allergic or sensitivity reaction, gastrointestinal symptoms, and a higher risk of some types of infection
• Warnings include: not suitable for people with a low WBC count

Gilenya (fingolimod)

• Benefit: blocks T cells from leaving lymph nodes
• Dose frequency: daily
• Common side effects include: flu-like symptoms, elevated liver enzymes
• Warnings include: can cause changes in blood pressure, liver function, and heart function

Mavenclad (cladribine)

• Benefit: reduces the number of T and B lymphocytes, which play a key role in the immune attack in people with MS, but it does not continuously suppress the immune system
• Dose frequency: divided into two treatment courses:
  • first course: an initial dose, followed by another dose 23 to 27 days later
  • second course: one dose at least 43 weeks after the previous course, followed by a second dose 23 to 27 days later
• Common side effects include: upper respiratory tract infection, headache, reduced levels of lymphocytes, a type of WBC
• Warnings include: may increase the risk of cancer; not suitable for anyone who wishes to conceive or become pregnant, whether male or female; not suitable during pregnancy

Ponesimod (Ponvory)

• Benefit: helps the lymph nodes retain certain white blood cells, which prevents them from circulating in the blood and entering the brain and spinal cord
• Dose frequency: usually as a 20 mg tablet, once daily
• Common side effects include: an increased risk of upper respiratory tract infection, liver problems, high blood pressure
• Warnings include: not suitable for people with a history of heart problems

Siponimod (Mayzent)

• Benefit: acts on immune cells to slow MS progression and reduces the number of relapses
• Dose frequency: 2 mg tablet once daily
• Common side effects include: slow heart rate, headache, high blood pressure, eye problems, slow heart rate, a higher risk of infections, lung problems, liver damage
• Warnings include: not suitable for people with a history of heart problems or stroke and those who are pregnant or planning to become pregnant

Tecfidera (dimethyl fumarate)

• Benefit: has anti-inflammatory properties, protects nerves and myelin from damage
• Dose frequency: twice daily
• Common side effects include: gastrointestinal changes, reduced WBC count, elevated liver enzymes
• Warnings include: can cause severe allergic reactions, including anaphylaxis

Vumerity (diroximel fumarate)

• Benefit: most likely modulates the immune response to reduce inflammation and may prevent damage to the brain and spinal cord
• Dose frequency: one capsule per day for 7 days, increasing to two capsules after 7 days with a high fat or high calorie snack or meal
• Common side effects include: flushing, redness or discoloration, itching, rash, nausea, vomiting, diarrhea, stomach pain, or indigestion
• Warnings include: an allergic or sensitivity reaction, gastrointestinal symptoms, a higher risk of various types of infection

Zeposia (ozanimod)

• Benefit: reduces cell damage due to inflammation by preventing certain WBCs from entering the central nervous system
• Dose frequency: one capsule daily
• Common side effects include: liver problems, high blood pressure, reduced heart rate, breathing problems, a higher risk of certain types of upper respiratory tract infections, and other infections
• Warnings include: not suitable for people with a history of heart problems or stroke

How do you choose an MS drug?

When deciding between oral, injectable, and IV treatment, many factors will be considered, such as:

• Frequency: Oral medications are taken daily, while many injectable medications are taken less frequently.
• Convenience: Oral medications may be given at home and are generally convenient to take. DMTs that are injected in the muscle (intramuscular) or under the skin (subcutaneously) are taken at home, which can be convenient if you or a family member learns how to inject the medication.
• Administration: Oral medications are taken by mouth, and injectable medications may be given through a port if you have one installed, injected (a shot), or given as part of an IV.

Other factors to consider when choosing specific medications and treatment options include:

• medication effectiveness
• side effects
• frequency of doses
• method used to administer the medication

The takeaway

The goal of MS treatment is to manage symptoms, control relapses, and slow the long-term progression of the disease. All MS treatments have benefits, side effects, and risks. The most important thing is that you take your treatment as prescribed, regardless of what treatment you’re on.

Injectable MS treatments come in several forms: injectables, self-injectables, intravenous, and infusions. Most injectables don’t have to be taken as often as oral medications, which are taken daily.

If the side effects or dosing schedule cause you to want to skip treatments, talk with your doctor. They can help you choose the best option for you.