MS Information for Pharmacists

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 DMTsⁱⁱ. 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.ⁱⁱⁱ The most common comorbidities in people with MS reported include depression and anxiety, hypertension, and hyperlipidemia.^iv 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 10% [2%–10%] 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.^v  
 
Summary points:  

• MS can occur in children but is uncommon. 

• Risk factors for MS in children include low vitamin D levels, smoking, exposure to second-hand smoke, and adolescent obesity. 

• If a child (below the age of 18) is diagnosed with MS, treatment with a DMT is recommended. 

• All DMTs used for adults with MS have been used in children with MS and are likely effective in controlling their MS. 

• 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.  

Pediatric Onset MS Additional Reading 

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: 

• spasticity  

• pain 

• bladder function 

• tremors 

• 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.

Non-Provincially Funded Vaccines (requires prescription drug insurance or payment): 

 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.^vii 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 antioxidants, 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, Asian, St. John’s wort, 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:   

• Does their policy have a maximum lifetime limit or annual limit for coverage?  

• Is the medication covered under their private drug plan? 

• What percentage of the drug cost is covered by their plan?  

• 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.