Multiple Sclerosis: medications and paying cash

Overview

In multiple sclerosis the immune system attacks myelin, the protective coating around nerve fibers in the brain and spinal cord. Early symptoms often include vision problems such as optic neuritis, weakness and stiffness with painful spasms, numbness or tingling, poor balance and bladder problems; fatigue, mood and cognitive changes are also common. Most people are first diagnosed with relapsing-remitting MS, in which attacks are followed by partial or complete recovery. It can evolve into secondary progressive MS, with fewer attacks but steady decline, while primary progressive MS worsens steadily from the start; a single first attack is called clinically isolated syndrome.

Disease-modifying therapies suppress or regulate the inflammation that drives the disease, reduce relapses and work best in relapsing forms, which labels define as clinically isolated syndrome, relapsing-remitting disease and active secondary progressive disease. Glatiramer acetate and the interferon betas are injected; dimethyl fumarate, diroximel fumarate, teriflunomide, fingolimod, siponimod and ozanimod are taken by mouth; natalizumab and ocrelizumab are infused, ocrelizumab also comes as an injection under the skin given by a health care professional, and ofatumumab is an antibody patients inject themselves. Each has its own monitoring: a blood count with lymphocytes and liver tests before dimethyl fumarate, then the blood count after six months and every six to twelve months after that; for teriflunomide, with boxed warnings for liver injury and harm to an unborn baby, liver tests within six months before starting and monthly for six months after, and pregnancy ruled out first; and for fingolimod and siponimod, an ECG, an eye examination, a blood count, liver tests and a varicella antibody test before the first dose, plus six hours of observation after the first fingolimod dose and a genetic CYP2C9 test before siponimod.

For a relapse, a prescriber can give a corticosteroid such as methylprednisolone for three to five days, usually into a vein and sometimes followed by a tapering course taken by mouth; the treatment speeds recovery but does not change the long-term course. Symptom medicines are separate: baclofen and tizanidine relax the spasticity that stiffens muscles and causes spasms, dalfampridine is approved to improve walking speed, and other symptoms, such as pain, have medicines of their own. Baclofen must not be stopped suddenly, because withdrawal has caused hallucinations and seizures, so the dose is lowered slowly. Tizanidine lowers blood pressure, can injure the liver, must not be taken with fluvoxamine, ciprofloxacin or other strong CYP1A2 inhibitors, and its tablets and capsules absorb differently with food, so one form is prescribed and kept to.

Choosing between the options when you pay cash

For a cash-paying patient, the first question is whether a generic exists. Dimethyl fumarate, teriflunomide, glatiramer acetate and fingolimod have FDA-rated generics; a glatiramer generic replaces the brand only at the same strength, since the 20 mg and 40 mg per mL syringes are not interchangeable. The FDA has also approved generics of diroximel fumarate (Vumerity) and siponimod (Mayzent), but an approval is not a product on pharmacy shelves, so ask what the pharmacy can order. Ozanimod (Zeposia) has no generic, and the interferon betas are biologics with no biosimilar, so every fill is the brand. Baclofen and tizanidine tablets are generics from many makers, and quotes for the same prescription differ between pharmacies; the baclofen liquids, tizanidine capsules and Ontralfy solution are separate products.

Some disease-modifying therapies are dispensed only through specialty pharmacies: Biogen states that Vumerity is not available at a local pharmacy and ships from a specialty pharmacy. Ask the prescriber’s office whether yours must go through a specialty pharmacy or a manufacturer program before requesting quotes. A first dose of fingolimod needs supervised observation and a start on siponimod needs the genetic test and a starter pack, so the clinic, not the pharmacy, sets the timing. Switching between therapies, glatiramer strengths or tizanidine forms is the prescriber’s decision; a pharmacy quotes only what is written.

Medicines at a glance

How the medicines in this group are supplied and usually taken. Each guide has the full details.

• Dimethyl Fumarate
  Delayed-release capsules
  Generic: Yes · Twice a day
• Teriflunomide
  Tablets
  Generic: Yes · Once a day
• Glatiramer
  Single-dose prefilled syringes for injection under the skin
  Generic: Yes · See the guide
• Baclofen
  Tablets (generic), Oral solution (generic and Ozobax DS), Oral suspension (Fleqsuvy and generic)
  Generic: Yes · Three times a day
• Tizanidine
  Tablets (Zanaflex and generic), Capsules (Zanaflex and generic), Oral solution (Ontralfy)
  Generic: Yes · Every 6 to 8 hours

Medications

Which of these is right for a given person is a decision for the prescriber. The guides explain what each drug is, how it is supplied, and why its cash price varies between pharmacies. No page on this site shows a price; prices come from pharmacies responding to your actual prescription.

Questions worth asking

• Is my prescription for a generic, and if a brand is written, why?
• Must my therapy come from a specialty pharmacy, or can a local pharmacy fill it?
• Which blood, eye or heart tests do I need before I start and during treatment?
• Is my tizanidine prescription for tablets or capsules, and should I take it with food or without?
• How should baclofen be lowered if I ever need to stop, and what if I run out?

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