Providing care to people living with MS is an important part of a pharmacist’s role. This page is designed to give pharmacists practical, up-to-date information about MS from care strategies to treatment options. Whether you are looking to enhance your understanding of available MS medications or learn how to better support people living with the disease, we want to make it easier for you. Your knowledge of MS and its management greatly enhances the care and well-being of people living with MS.
MS is the most common neurological disease of the central nervous system (brain and spinal cord). Approximately 90,000 Canadians are living with the disease. MS is usually diagnosed between 20 and 49 years of age and is up to three times more likely to occur in women than men. MS impacts each person differently over their lifetime.
Symptoms of MS can be unpredictable and vary greatly from person to person. Many symptoms are invisible to everyone but the person living with the disease. Symptoms will depend on the area within the central nervous system (CNS) that is involved. Fatigue, problems with balance, weakness, sensory changes like tingling or numbness, vision problems, bladder and bowel problems, and cognitive and mood changes may be reported by people living with MS. It’s unlikely that people will experience all the symptoms listed above.
Disease activity and Progression
In MS, the immune system does not behave normally. This leads to inflammation that damages the protective covering around nerve fibers (myelin). Over time, the nerve fibers are also damaged. The damage (lesions) blocks or slows down communication between nerves and the body. This causes neurological symptoms like weakness, tingling or numbness, and changes in thinking or memory.
MS can be described as active or inactive. Relapses and new or growing lesions seen on MRI scans or both mean MS is active. When there are no relapses or visible changes on MRI scans then MS is inactive. However, even if MS is inactive a person with MS may still have ongoing symptoms. Neurologists use MRI scans, physical exams, and other biomarkers (blood or spinal fluid tests) to check if MS is active or not.
Each person will experience MS differently. This includes how their disease progresses. Disability progression can result from relapses. Progression also occurs independent of relapses due to ongoing inflammation and other processes in the brain and spinal cord. Both play a role in disability progression over time, starting in the early stages of MS and continuing throughout the disease.
Brain reserve is the brain’s ability to protect against damage due to disease or aging. People with more reserve may experience more damage to the brain without showing any symptoms. The brain also has some natural ability to repair itself. As we get older, this ability decreases, and the brain can’t repair itself as well. In MS, this natural loss of brain reserve can make old damage show up as disability. There are currently no medications to treat nerve repair (remyelination) but this is an area of ongoing and promising research.
Types of MS
MS is a continuous disease process because it progresses through different stages over time. Everyone with MS has a unique disease course that can vary widely in severity, symptoms, progression rate, and response to treatment. Based on their medical history and an exam by a neurologist, people may be initially diagnosed with one of the following:
Radiologically isolated syndrome (RIS) refers to demyelination seen on MRI which is suggestive of MS, but without any physical symptoms or signs of the disease. Nearly half of all people with RIS will be diagnosed with MS within ten years.
Clinically isolated syndrome (CIS) refers to a single episode of neurological symptoms suggestive of MS. Not everyone with CIS will be diagnosed with MS, however over the longer term, about 80% of people develop more MS disease activity that leads to a diagnosis of MS. Regular follow-up with a neurologist and brain imaging may be recommended to ensure appropriate treatments and supports are ready at the right time.
Relapsing-Remitting MS
Between 85-90% of people living with MS are initially diagnosed with relapsing remitting MS (RRMS), characterized by neurological symptoms called relapses (also called attacks, exacerbations, and flare-ups), followed by complete or partial recovery (remission).
Progressive MS
Some people with RRMS will transition to a phase of the disease called secondary progressive MS (SPMS). This phase of the disease has fewer relapses with increasing disability progression. The rate of worsening is different for everyone and typically is more gradual than the worsening experienced with MS relapse.
About 10% of people will be diagnosed with primary progressive MS (PPMS). PPMS is characterized by a slow accumulation of disability, which usually doesn’t include relapses. Overall, there are no periods of significant improvement or return of function over time. PPMS is usually diagnosed later than other forms of MS and affects men and women equally.
The Expanded Disability Status Scale (EDSS) is a method of quantifying disability in MS and monitoring changes in the level of disability over time. It’s a way of measuring how much someone is affected by their MS. The EDSS scale ranges from 0 to 10 in 0.5-unit increments that represent higher levels of disability. EDSS steps 1.0 to 4.5 refer to people with MS who can walk without any aids. EDSS steps 5.0 to 9.5 are categorized as an impairment to walking.
Scoring is based on an examination by a neurologist and is based on measures of impairment in eight functional systems (FS). A functional system (FS) represents a network of neurons in the brain with responsibility for particular tasks. Neurologists use it to monitor changes in the level of someone’s disability over time. While the EDSS is helpful in clinical practice, clinical trials, and DMT reimbursement criteria, it has several limitations. The scoring relies on the examining neurologist, which can be subjective, and it’s not sensitive enough to capture subtle changes in worsening or improvement. It also focuses heavily on ambulation and lower limb function and so it doesn’t give a comprehensive picture of all areas of disability progression such as cognitive change, fatigue, or other impacts of the disease on quality of life.
The EDSS measures the following areas, although it primarily focuses on physical and neurological functions, with a significant emphasis on mobility and ambulation:
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pyramidal – muscle weakness or difficulty moving limbs
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cerebellar – ataxia, loss of balance, coordination, or tremor
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brainstem – problems with speech, swallowing, and nystagmus
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sensory – numbness or loss of sensations
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bowel and bladder function
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visual function - problems with sight
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cerebral functions - problems with thinking and memory
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Functional System (FS) Disability Score |
Description |
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0.0 |
Normal neurological exam |
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1.0 |
No disability, minimal signs in one FS |
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1.5 |
No disability, minimal signs in more than one FS |
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2.0 |
Minimal disability in one FS |
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2.5 |
Mild disability in two FS |
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3.0 |
Moderate disability with no impairment in walking |
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3.5 |
Fully ambulatory but with moderate disability in one FS |
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4.0 |
Fully ambulatory without aid or rest for 500 meters. Self-sufficient for 12 hours a day with some significant disability |
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4.5 |
Fully ambulatory without aid or rest for 300 meters. Up and about much of the day, able to work a full day |
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5.0 |
Able to walk without aid or rest for 200 meters. Disability severe enough to impair full daily activities |
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5.5 |
Able to walk without aid or rest for 100 meters. Disability severe enough to preclude full daily activities |
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6.0 |
Requires a walking aid to walk about 100 meters with or without resting |
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6.5 |
Requires two walking aids to walk about 20 meters without resting |
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7.0 |
Unable to walk beyond 5 meters even with aid. Essentially restricted to a wheelchair. Can wheel self in a standard wheelchair and transfer alone |
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7.5 |
Unable to take more than a few steps or walk beyond 5 meters even with an aid. Essentially restricted to a motorized wheelchair (can wheel self in a standard wheelchair, though not for a full day). May need assistance with transfers |
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8.0 |
Essentially restricted to bed, chair, or pushed in a wheelchair. May be out of bed much of the day. Retains many self-care functions and generally has effective use of arms |
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8.5 |
Essentially restricted to bed much of the day. Has some effective use of arms and retains some self-care functions |
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9.0 |
Confined to bed. Can communicate and eat |
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9.5 |
Confined to bed and totally dependent. Unable to communicate effectively or eat/swallow |
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10.0 |
Death due to MS |
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EDSS steps 1.0 to 4.5 refer to fully ambulatory people EDSS steps 5.0 to 9.5 are defined by the impairment to ambulation |
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Many strategies can be used to maintain overall wellness and improve quality of life, such as physical activity, rehabilitation and following an overall healthy lifestyle with a balanced diet. In addition to wellness strategies, there are several therapeutic options for MS. Disease-modifying therapies (DMTs) are medications that modify or influence the underlying disease course. DMTs do not treat symptoms of MS but target the inflammation that causes damage to the CNS. There are also medications to treat relapses and diverse medications that help relieve the various symptoms that can be experienced in MS.
Disease-modifying therapies (DMTs)
DMTs are designed to reduce the frequency and severity of relapses, reduce the accumulation of lesions (damaged or active disease areas) within the brain and spinal cord, and slow the accumulation of disability. The best course of action is to control the inflammation and prevent irreversible tissue damage early on. Current treatments available target the inflammatory process of MS; they are not typically effective for most people diagnosed with progressive disease without inflammatory activity.
See MS Treatments (MS Canada)
CPS
Symptom management
MS symptoms can be managed through medications, lifestyle and supportive therapies such as rehabilitation, supportive counseling, and lifestyle modifications such as regular exercise, a balanced diet, and healthy sleep hygiene practices. In addition, some patients may require education related to medication administration, potential side effects, and the importance of adherence.
People living with MS may be at a higher risk for polypharmacy due to symptom management medications, increased comorbidities, and side effect management of certain DMTs. This can lead to potential issues such as drug interactions, long-term safety, drug adherence, and increased cost. Polypharmacy in patients with MS may experience increased hospitalizations, relapses, fatigue, and healthcare utilization.The most common comorbidities in people with MS reported include depression and anxiety, hypertension, and hyperlipidemia. It is recommended that healthcare providers regularly review medications, including supplements and over-the-counter drugs, to identify those experiencing polypharmacy and who would benefit from a comprehensive medication review.
Polypharmacy in MS Additional Reading:
Beranek L, Fenton K, Obeidat AZ. Identification, management, and prevention of polypharmacy in multiple sclerosis. Practical Neurology (US). 2024;23(1):35-38.
Chertcoff A, Ng HS, Zhu F, Zhao Y, Tremlett H. Polypharmacy and multiple sclerosis: A population-based study. Mult Scler. 2023 Jan;29(1):107-118. doi: 10.1177/13524585221122207. Epub 2022 Oct 27. PMID: 36301629; PMCID: PMC9896267.
Thelen J, Zvonarev V, Lam S, Burkhardt C, Lynch S, Bruce J. Polypharmacy in Multiple Sclerosis: Current Knowledge and Future Directions. Mo Med. 2021 May-Jun;118(3):239-245. PMID: 34149084; PMCID: PMC8210980.
Pediatric Onset MS
Up to 5% of people with MS experience their first symptoms in childhood or adolescence. MS onset in childhood [before 10–12 years of age] accounts for 1% of all MS cases. Early treatment of pediatric-onset MS is recommended. All DMTs approved for the adult population have been used in pediatric-onset MS and are likely to be efficacious. Only one DMT carries a Health Canada pediatric indication (fingolimod) however coverage is limited to private or compassionate use. Other DMTs are used off-label in this population. Treated children and adolescents with MS should be monitored comprehensively, with standardized monitoring according to the specific DMT.
Summary points:
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MS can occur in children but is uncommon.
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Risk factors for MS in children include low vitamin D levels, smoking, exposure to second-hand smoke, and adolescent obesity.
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If a child (below the age of 18) is diagnosed with MS, treatment with a DMT is recommended.
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All DMTs used for adults with MS have been used in children with MS and are likely effective in controlling their MS.
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Once on a DMT, children with MS are monitored closely over time in terms of how they are doing on their DMT, how well their MS is controlled, and what side effects they are experiencing.
Pregnancy and Breastfeeding and DMTs
Women who are considering pregnancy are encouraged to speak with their neurologist. If a planned pregnancy is possible, it is best to do so when the disease has been stable for some time. Women should be counseled on DMT use as some DMTs are contraindicated during the time of trying to conceive, pregnancy, and breastfeeding. It is important to understand the potential risks of a DMT with pregnancy and breastfeeding. Research suggests that breastfeeding may help control disease activity following delivery. Female MS patients of childbearing age should use a reliable method of contraception. Discontinuation of DMTs is generally recommended before conception.
Summary points:
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If able to plan a pregnancy, pregnancy is most ideally planned for when women with MS have been stable with their disease for a while.
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Encourage conversations between patients and their neurologists when considering pregnancy.
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Some DMTs should not be used in women with MS if there is a chance they may become unexpectedly pregnant soon.
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Breastfeeding can help control MS disease activity after delivery.
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Some DMTs are thought to be safer during breastfeeding than others.
Pregnancy and Breastfeeding Additional Reading
1 Graham EL, Bove R, Costello K, Crayton H, Jacobs DA, Shah S, Sorrell F, Stoll SS, Houtchens MK. Practical Considerations for Managing Pregnancy in Patients With Multiple Sclerosis: Dispelling the Myths. Neurol Clin Pract. 2024 Apr;14(2):e200253. doi: 10.1212/CPJ.0000000000200253. Epub 2024 Feb 13. PMID: 38585436; PMCID: PMC10996912.
Iyer, P., Dobson, R. Multiple Sclerosis in Pregnancy: A Commentary on Disease Modification and Symptomatic Drug Therapies. Neurol Ther 12, 1–10 (2023). https://doi.org/10.1007/s40120-022-00421-0
Dobson R, Rog D, Ovadia C, et al. Anti-CD20 therapies in pregnancy and breastfeeding: a review and ABN guidelines. Practical Neurology 2023;23:6-14.
Many people with MS use or consider using medical cannabis to manage symptoms. The two most notable cannabinoids are tetrahydrocannabinol (THC) and cannabidiol (CBD). THC is known to have psychoactive effects such as anxiety, psychosis, and cognitive impairment, whereas CBD has analgesic and anti-inflammatory properties. These products activate receptors through the body involved in processes such as pain, mood, memory, and appetite.
Nabiximols (Sativex) is a pharmaceutical preparation of cannabis in an oral spray and is the only medicinal cannabis derivative approved for the treatment of neuropathic pain in adults with MS in Canada. Sativex contains a 1:1 ratio of THC and CBD. Sativex is not covered through all provincial drug plans.
In Canada, it is determined that individuals who have demonstrated a medical need for cannabis have a right to access it, though it is not an approved drug or medicine. Cannabis use in MS patients is typically used to relieve symptoms of:
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spasticity
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pain
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bladder function
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tremors
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sleep
When counseling people with MS about medical cannabis, provide some information on the roles of THC and CBD, highlighting their benefits and effects. It’s important to discuss the different forms of cannabis, and their respective onset times and durations. Starting with a low dose and gradually increasing it is crucial. The persons current medications should be reviewed to avoid adverse interactions and inform them about potential side effects like dizziness and dry mouth. People should be aware of the legal status of cannabis in their area and the importance of regular follow-ups. Providing comprehensive education on the safe and effective use of cannabis is essential for optimal patient outcomes.
Factors that can influence the adverse effects a person may experience include how often they use cannabis, the quantity administered, how it is taken, the proportion of cannabinoids, and their tolerance to cannabis.
Currently, cannabis for medical purposes is not covered by provincial drug plans and is rarely covered under private drug plans. Patients can check with their providers to confirm their coverage status. However, if they are a veteran, they may have coverage through Veterans Affairs Canada. For additional support and information about cannabis, patients may connect with Canadian Cannabis Clinics (CCC). Canadian Cannabis Clinics provides individuals with access to medical experts knowledgeable in the use of medical cannabis. A CCC healthcare practitioner will assess whether medical cannabis appropriate for the individual and a medical cannabis educator will guide and support people through the entire process.
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General immunization information |
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It’s recommended that people have their immunizations updated before starting a disease-modifying therapy (DMT). They will most likely visit their public health nurse, pharmacist, or family physician to have immunizations completed. There is no causal association between the vaccines for MMR (measles, mumps, and rubella), hepatitis B and influenza vaccines, and autism spectrum disorders or demyelinating diseases — including MS. There was no change in risk of developing MS after receiving a vaccination against seasonal influenza, hepatitis B, human papillomavirus (HPV), measles-mumps-rubella, variola, tetanus, Bacillus Calmette-Guérin (BCG), polio, or diphtheria; nor was there an increased risk of relapse following vaccination against seasonal influenza. People with MS should get vaccinated against influenza annually; influenza can worsen the symptoms of MS. The following vaccinations do not have published studies related to their safety in MS: meningitis, typhoid, hepatitis A, pertussis, and Japanese encephalitis. Immunizations are recommended for as many MS medications can alter or suppress the immune system, which could make them more susceptible to diseases. Live, attenuated vaccines are generally not recommended for people with MS because their ability to cause disease has been weakened but not inactivated. If they require any live vaccine, it should be administered at least 6 weeks before they begin their treatment for MS. Once they have begun MS medication, and they receive a vaccine, they may only get partial benefit from it - so it is best to have immunizations updated before starting a DMT. More detailed information on vaccinations and MS can be found at the following websites:
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Non-Provincially Funded Vaccines (requires prescription drug insurance or payment):
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Vaccine |
Injection instructions / timeline |
Recommendations |
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Hepatitis A and B / TwinRix |
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Herpes Zoster - Shingrix |
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Human Papillomavirus vaccine (HPV) |
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Meningococcal conjugate (MenC-ACYW or equivalent) |
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Additional resources: Cleveland Clinic Vaccination recommendation
The connection between vitamin D and MS demonstrates that a deficiency in vitamin D is associated with an increased risk of MS. Other factors contributing to an increased risk of developing MS include smoking and obesity. People with a sibling, parent, or child with the disease, is considered at higher risk of developing MS. Everyone can decrease their chances of developing MS by making sure they are getting enough vitamin D every day by following Health Canada recommendations. Some neurologists may recommend that their patients take higher levels of vitamin D to reach the optimal range.
Vitamin D is not an effective treatment for MS. Vitamin D supplements should not be taken instead of a disease-modifying therapy. It can be taken safely in combination with a disease-modifying therapy.
Evidence for the safety and efficacy of vitamins A, B6, B12, C, and E in MS has not been well established. Higher doses of B6 (50mg to 1,000mg) may cause symptoms similar to those seen in MS such as tingling, numbness, and pain.
Certain dietary supplements that stimulate the immune system could worsen MS or interfere with the therapeutic effects of MS medications. These include skullcap, germanium, chaparral, comfrey, kava kava, echinacea, ashwagandha, alfalfa, astragalus, cat’s claw, garlic, St. John’s wort, Asian ginseng, and Siberian ginseng.
Many supplements have limited or inconclusive evidence to support their safety or efficacy in MS so patients are encouraged to receive essential vitamins and minerals by following Canada’s Food Guide, and if they do wish to supplement, to do so in consultation with a health care provider using the Health Canada recommended dietary intake.
DMT therapy is costly, and most drug insurance plans require people to meet specific criteria before they will pay for their drugs. Drug plans and reimbursement criteria vary by jurisdiction. This section is an overview of drug insurance coverage for MS DMTs. MS DMTs are expensive, and most people cannot afford to pay out of pocket for them. Having drug insurance is important to cover all or most of the cost of the medications. Drug insurance is either private or public.
Private Insurance Plans
Private insurance is normally a group plan provided by their employer or their spouse’s employer. It can also be a plan that they have applied for independently to provide coverage for themselves or their family. The patient will have contacted their insurance company or patient support program already to discuss options available to fund their choice of medication. The insurance companies will require their plan number and the DIN of the medication that they have chosen.
Questions for the patient to inquire about with their insurance company:
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Does their policy have a maximum lifetime limit or annual limit for coverage?
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Is the medication covered under their private drug plan?
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What percentage of the drug cost is covered by their plan?
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Is their neurologist expected to provide documentation or fill out forms?
Often, private insurance will require a special authorization or prior authorization form to be completed, and they have to be “approved” by the insurance company before they can obtain medication from the pharmacy. Insurance companies have specific criteria that must be met to be covered under their plans. The criteria are different for each medication.
Unless patients have 100% private insurance coverage through work their employer that does not have a yearly or lifetime maximum, the most economical way to obtain and pay for medication for those who are eligible is via provincial or territorial government public drug program. Sometimes it is necessary to have both private and public drug insurance, to cover the cost of medications.
Public Drug Insurance
Public insurance is provided by the provincial government to eligible Canadians. It it’s generally for patients who have no private insurance, or those needing additional insurance because their private insurance is insufficient for their medications. Public drug plans vary significantly across the country in which DMT they cover, reimbursement criteria, and renewal times.
Renewal of MS Medication
Regardless of whether the insurance provider is private or public, people living with MS are typically required to be seen by their neurologist to have their medication reviewed and renewal forms completed. If the insurance forms are not completed for drug renewal, patients may not be able to get the medication from the pharmacist. Renewal times for MS DMTs vary across the country.
Off DMT for an Extended Period
If a person needs to be off their DMT for an extended period (such as attempting to conceive, pregnancy, or breastfeeding), there is typically a two-year time limit they are permitted to be off a DMT for these purposes. This time frame may be province specific so the person will need to inquire about this with their clinic and health care team. They must also be aware of how the break from medication affects their public or private insurance for reimbursement. The person will need a renewal letter from their neurologist before the 2 years are complete, or they will need to re-qualify for coverage if they are off medication for longer than 2 years.
They can utilize the pharmaceutical support programs (PSP) for each of the MS medications to provide support. Where available, reimbursement insurance specialists will help guide them through the process of starting or restarting an MS DMT.