Multiple Sclerosis Treatment 101: How to Choose the Right Medication and Know It's Working

The most important decision you'll make after an MS diagnosis isn't whether to start treatment – it's which treatment to choose, and how to tell if it's actually working. With over 20 FDA-approved medications available, each with different mechanisms, schedules, and effectiveness levels, the landscape can be genuinely complex.

Yet most newly diagnosed patients leave their first neurology appointment with more questions than answers. Which medication is right for your specific situation? How do you balance effectiveness against convenience and side effects? And perhaps most critically: once you start treatment, how do you know if it's preventing damage you can't see or feel?

This guide cuts through the complexity. We'll walk you through the strategic framework for choosing an MS medication that fits your life, and give you the concrete measures – from MRI metrics to emerging biomarkers – that tell you whether your treatment is doing its job. By the end, you'll have the knowledge to be an active partner in your MS care.

Understanding MS Medications: The Basics

Before we dive into choosing and monitoring treatment, let's cover the essentials.

Multiple sclerosis is an autoimmune condition where your immune system mistakenly attacks the protective covering (myelin) around nerve fibers in your brain and spinal cord. This damage can cause a wide range of symptoms and, over time, can lead to disability if left untreated.

The primary medications we use are called disease-modifying therapies (DMTs). Think of them as a shield for your nervous system. While DMTs can't reverse damage that's already occurred, they work to:

• Reduce the frequency and severity of relapses (flare-ups of symptoms)
• Prevent or slow down the formation of new lesions (areas of damage visible on MRI)
• Delay disability progression over time

It's important to understand that DMTs work in the background. You might not "feel" dramatically better day-to-day, especially at first. Instead, they're preventing future attacks and damage you can't see or feel. This is why starting treatment early – ideally soon after diagnosis – gives you the best chance of staying healthy long-term.

Part 1: How to Choose the Right MS Medication for You

With more than 20 FDA-approved MS medications available, choosing the right one can feel overwhelming. The good news? This abundance of options means we can find a therapy that fits your specific situation, preferences, and goals.

The Three Key Factors in Treatment Selection

When selecting an MS treatment, you and your neurologist will weigh three main considerations:

1. Efficacy: How Effective Is It?

Different medications have different levels of effectiveness at preventing relapses and MRI activity. Generally speaking:

• Older injectable medications (like interferons) have moderate effectiveness
• Many oral medications have good to high effectiveness
• Newer monoclonal antibody therapies (infusions and injections) tend to have the highest effectiveness

Some patients and doctors prefer to "start strong" with a highly effective therapy right away, especially if your MS appears active. Others prefer beginning with a moderate therapy and escalating if needed. While clinical trials are actively comparing these two approaches, accumulating evidence increasingly favors starting strong – particularly because MS tends to be most active in the early years after diagnosis. The good news? As patients get older and their disease naturally becomes less active, many can transition to safer medications with lower monitoring requirements.

Important consideration: More aggressive MS (frequent relapses, many lesions on MRI, rapid disability progression) typically warrants more aggressive treatment from the start.

2. Safety and Side Effects

More effective medications sometimes come with higher risks or more monitoring requirements. For example:

• Older medications generally have decades of safety data and lower serious risk profiles
• Newer high-efficacy therapies may require regular blood tests, infusion monitoring, or screening for specific complications

Your medical history, lifestyle, and comfort level with risk will influence this decision. We'll discuss your individual risk factors and what monitoring will look like for each option.

3. Convenience and Lifestyle Fit

How a medication fits into your daily life matters enormously for long-term success. Consider:

• Daily pills vs. self-injections vs. infusions at a medical center
• Frequency: Some treatments are daily, others weekly, monthly, or even just twice yearly
• Your work schedule and travel plans
• Whether you're comfortable with needles or prefer oral medication
• Future family planning considerations

For example, a busy professional in Los Angeles might prefer a medication that requires only two infusions per year rather than daily pills or weekly injections. A patient with needle anxiety might strongly prefer an oral option. These preferences are completely valid and should be part of your decision.

Your Treatment Options: A Comprehensive Overview

Let's explore what's available. MS treatments have come a long way in recent decades, and the variety of therapies today means most patients can find an effective option that works for their lifestyle.

Injectable Disease-Modifying Therapies

These were the first DMTs available and have been used for decades:

Interferon Beta Medications:

• Avonex (once weekly injection)
• Rebif (three times weekly)
• Betaseron, Extavia (every other day)

Glatiramer Acetate (Copaxone, Glatopa):

• Daily or three times weekly injection

What to know: These medications have moderate effectiveness and extensive long-term safety data. Common side effects include flu-like symptoms (for interferons) and injection-site reactions. While newer therapies have largely superseded these options, they remain appropriate for some patients, particularly those seeking a well-established safety profile.

Oral Disease-Modifying Therapies

Pills were a game-changer in MS treatment, offering convenience without needles:

Sphingosine-1-Phosphate (S1P) Modulators:

• Fingolimod (Gilenya) – once daily
• Siponimod (Mayzent) – once daily
• Ozanimod (Zeposia) – once daily
• Ponesimod (Ponvory) – once daily

These work by keeping immune cells in the lymph nodes, preventing them from attacking the nervous system. They require cardiac monitoring at the first dose and regular eye exams.

Fumarates:

• Dimethyl fumarate (Tecfidera) – twice daily
• Diroximel fumarate (Vumerity) – twice daily
• Monomethyl fumarate (Bafiertam) – twice daily

These have good efficacy with manageable side effects (flushing and stomach upset initially, which often improve over time).

Other Oral Options:

• Teriflunomide (Aubagio) – once daily
• Cladribine (Mavenclad) – two treatment courses over two years, then none needed

What to know: Oral medications offer excellent convenience and generally good effectiveness. They're popular choices for patients who want to avoid injections but still get strong protection against MS activity.

Monoclonal Antibody Therapies: The High-Efficacy Options

This category represents some of the newest and most powerful MS treatments available. These are given as infusions at a medical facility or as self-injections:

Anti-CD20 B-Cell Therapies:

• Ocrelizumab (Ocrevus) – infusion every 6 months
• Ofatumumab (Kesimpta) – self-injection once monthly (after loading doses)
• Ublituximab (Briumvi) – infusion every 6 months

These therapies target B-cells (a type of immune cell) and have shown impressive results in clinical trials. Ocrevus was the first MS medication approved for both relapsing MS and primary progressive MS. Studies show these B-cell therapies significantly reduce relapse rates and new MRI lesions compared to older medications.

What to know: These are among our most effective tools against MS. They require monitoring for infusion reactions and infection risk, but many patients love the convenience of just two treatments per year (for the infusions) or monthly self-injections at home (for Kesimpta).

Natalizumab (Tysabri):

• Infusion every 4 weeks

An extremely effective medication that can dramatically reduce MS activity. It requires regular monitoring for a rare but serious brain infection called PML (progressive multifocal leukoencephalopathy) through JC virus antibody testing.

Alemtuzumab (Lemtrada):

• Two annual courses of infusions, then none typically needed

A powerful therapy administered as two treatment courses. It requires extensive monitoring for autoimmune side effects, but for some patients, it offers the possibility of long-lasting disease control.

Understanding Side Effects: What to Expect

Every medication comes with potential side effects. Let's talk honestly about what you might experience:

Injectable Medications:

• Injection-site reactions (redness, soreness) – very common but usually mild
• Flu-like symptoms with interferons (fatigue, chills, muscle aches) – often improve after the first few months

Oral Medications:

• Flushing and stomach upset (especially with fumarates) – usually temporary
• Increased risk of infections due to immune effects
• Hair thinning (with teriflunomide)
• Liver enzyme elevations – monitored with regular blood tests

Monoclonal Antibodies:

• Infusion reactions (itching, flushing, feeling unwell during or shortly after infusion) – usually manageable with premedication
• Increased infection risk, particularly respiratory and urinary tract infections
• For Tysabri specifically: PML risk (rare but serious brain infection) – requires regular JC virus monitoring
• For Lemtrada: secondary autoimmune conditions – requires monthly monitoring for years after treatment

Important: Not everyone experiences side effects, and when they do occur, they're often manageable. Additionally, every medication we prescribe comes with careful monitoring to catch and address any problems early.

The Decision-Making Process: It's a Partnership

The most important thing to know: you're not alone in this decision. The best treatment choice comes from an open conversation between you and your neurologist, where you discuss:

• Your treatment goals (maximum efficacy vs. minimal side effects vs. convenience)
• Your MS characteristics (how active your disease appears)
• Your medical history and any other health conditions
• Your values and lifestyle priorities

Come to your appointments prepared. Write down questions like:

• Why are you recommending this particular medication for me?
• What are the most common side effects I might experience?
• What serious risks should I know about, and how will you monitor for them?
• How will this fit into my daily routine?
• What happens if this medication doesn't work well for me?

Your input matters. Research shows that when patients actively participate in choosing their MS therapy, they're more satisfied with treatment and more likely to stick with it long-term.

Special Considerations

Family Planning: If you're thinking about pregnancy in the near future, this is a crucial factor in medication selection. Some DMTs are safer during pregnancy than others, and planning ahead allows for the smoothest transition.

Other Medical Conditions: Conditions like heart disease, liver problems, or a history of certain infections may make some MS medications less suitable. Be sure to share your complete medical history.

Long-Term Goals: Are you hoping for a "set it and forget it" treatment? Or are you comfortable with frequent monitoring if it means higher effectiveness? Your long-term preferences matter.

Part 2: How to Know If Your MS Medication Is Working

Once you've chosen and started a treatment, the next big question is: "How do I know it's helping?" This is one of the most common concerns we hear from newly diagnosed patients – and it's completely understandable.

The challenge with MS medications is that they work in the background. You're taking a medication regularly (or getting infusions), possibly dealing with side effects, and wondering: "Is this actually preventing anything?" Here's exactly how your neurologist will assess whether your treatment is effective.

The Gold Standard Measures of Treatment Success

1. Fewer or No Relapses

A major goal of DMT therapy is reducing relapses – those periods when new symptoms appear or existing ones worsen significantly. Your doctor will compare your relapse rate before and after starting treatment.

What success looks like: If you had two relapses in the year before starting medication and zero relapses in the year after, that's a clear sign the therapy is working.

Important note: If you experience a relapse within the first few months of starting a new medication, it doesn't necessarily mean the treatment has failed. Many DMTs take time to reach their full protective effect.

2. Stable or Improved MRI Scans

Regular brain and spinal cord MRIs are like taking snapshots of your MS activity. These scans are one of the most objective ways to monitor your disease.

What your neurologist is looking for:

• New lesions (areas of damage)
• Enlarging existing lesions
• Gadolinium-enhancing lesions (indicating active inflammation)
• Brain volume loss (atrophy) over time

What success looks like: If your follow-up MRIs show no new or growing lesions, it's excellent evidence that your medication is preventing disease activity. Stable MRIs mean your DMT is doing its job as a shield, even if you still have some symptoms from previous damage.

Monitoring schedule: Most neurologists recommend an MRI about 3 months after starting a new medication to establish a baseline for future comparisons. This is important because any new lesions appearing in those first few months don't necessarily indicate treatment failure – they may represent disease activity that was already underway before the medication took full effect. After this baseline scan, MRIs are typically done every 12 months, especially in the first few years. After several years of stability, the frequency may be reduced.

3. No Worsening Disability

Beyond relapses and MRIs, your doctor will track your neurological function through regular exams. This might include tests of your:

• Walking speed and endurance
• Coordination and balance
• Vision and eye movements
• Strength and sensation
• Cognitive function

Some neurologists use standardized disability scales (like the EDSS - Expanded Disability Status Scale) to measure changes over time with more precision.

What success looks like: If your level of function remains stable – or even improves – without new symptoms developing, your treatment is doing its job. Remember, the goal isn't necessarily to improve function that was already affected (though sometimes this happens as inflammation resolves). The goal is to prevent new disability from accumulating.

4. Neurofilament Light Chain (NfL) Blood Test: A New Window into MS Activity

One of the most exciting advances in MS monitoring is the neurofilament light chain (NfL) blood test – a cutting-edge biomarker that's becoming increasingly available.

What is NfL? Neurofilament light chain is a protein released into the bloodstream when nerve cells are damaged. Think of it as a "nerve damage marker" – when MS is actively attacking your nervous system, NfL levels rise. When disease activity is controlled, NfL levels stay low.

Why this matters: Unlike MRI scans (which you might get once or twice a year) or relapses (which you hope never to have), an NfL blood test can be done at routine office visits. It provides a more continuous, real-time picture of whether your MS is active or quiet.

How it's used in practice:

• Baseline measurement: When you start a new treatment, we can measure your NfL level
• Monitoring over time: Subsequent tests show whether levels are decreasing (good – means treatment is working) or remaining elevated (may indicate breakthrough disease activity)
• Early warning system: Rising NfL levels might detect disease activity before it shows up on MRI or causes symptoms, allowing us to adjust treatment proactively

What success looks like: NfL levels that decrease after starting treatment or remain in the low/normal range indicate your medication is effectively controlling inflammation. Stable, low NfL over time is associated with better long-term outcomes.

The advantage: This test can help answer the "is my medication working?" question more frequently and objectively than waiting months between MRI scans. It's particularly useful when there's uncertainty about whether treatment is optimal.

Current status: While having its limitations, NfL testing is increasingly available at specialized MS centers and is becoming part of the standard toolkit for monitoring treatment response. Ask your neurologist whether this test is available and appropriate for your care.

The Timeline: Patience Is Essential

Here's a critical point that many newly diagnosed patients don't realize: Most MS medications take several months to reach their full effectiveness.

During this initial period:

• Continue taking your medication exactly as prescribed
• Maintain regular follow-up appointments
• Keep a symptom journal to track any changes (even subtle ones you might otherwise forget)
• Don't panic if you don't feel dramatically different right away

Think of it this way: your medication is working hard in the background to prevent future attacks, even if you don't feel anything happening in the moment.

What Success Actually Feels Like

Many patients expect to "feel better" on MS medication, but that's not always how it works. Here's the reality:

What you might NOT notice:

• You probably won't feel your medication actively working day-to-day
• Your existing symptoms may not improve immediately (though some do as inflammation resolves over time)
• You might not feel different at all physically

What you SHOULD see over time:

• No new relapses (or significantly fewer than before)
• Stable MRI scans with no new lesions
• No new symptoms or worsening of existing ones
• Low or decreasing NfL levels (if monitored)

The key insight: The absence of disease activity is success. When you have a year without relapses, stable MRIs, low biomarkers, and no new disability, that's your medication working – even if you still have some lingering symptoms from before you started treatment.

Warning Signs That Treatment May Not Be Working

While we encourage patience, there are situations where a treatment change should be considered:

• New relapses after the first several months on treatment (especially if they're as frequent or more frequent than before)
• New or enlarging MRI lesions on follow-up scans
• Progressive worsening of neurological function without obvious relapses
• Persistently elevated NfL levels despite treatment
• Intolerable side effects that significantly impact your quality of life

If any of these occur, it doesn't mean you've failed – it means it's time to explore other options. And the good news? We have many alternatives to try.

Keeping Track: Tools for Monitoring

To help answer the "is it working?" question, consider:

Keep a symptom journal: Note new symptoms, changes in existing symptoms, and any relapses. Apps or simple notes in your phone work well.

Track your appointments and tests: Keep a record of when you have MRIs, blood work (including NfL if available), and neurological exams so you can see trends over time.

Document side effects: This helps distinguish between MS symptoms and medication side effects, and informs decisions if treatment changes are needed.

Celebrate stability: It's easy to focus on any remaining symptoms and forget to appreciate stability. If you've gone months or years without a relapse or new MRI activity, that's genuinely worth celebrating.

Can You Switch Treatments If Needed?

Absolutely, and this is important to know upfront: you're not locked into any medication forever.

Why Patients Switch Medications

There are several good reasons you might change treatments:

1. Breakthrough Disease Activity If you're having relapses or showing new MRI lesions despite being on medication for an adequate trial period, it may be time to escalate to a more effective therapy.

2. Side Effects If a medication is causing side effects that significantly affect your quality of life, we'll work with you to find an alternative.

3. Lifestyle Changes Major life changes might prompt a treatment switch. Planning for pregnancy, for instance, requires careful consideration of which MS medications are safest. Career changes or travel plans might also influence your choice.

4. New Treatment Options As new, more effective therapies become available, you might choose to switch to take advantage of advances in MS care.

The Switching Process

Never stop or change your medication on your own. MS medications affect your immune system, and stopping abruptly can sometimes trigger disease activity. Any changes should be planned with your neurologist.

When we switch medications, we'll:

• Discuss why a change is appropriate and what alternatives make sense
• Time the switch carefully (some medications require washout periods, while others can be transitioned more quickly)
• Monitor you closely during and after the transition with exams, MRIs, and potentially NfL testing
• Adjust the plan if needed

Regular Re-Evaluation Is Standard Care

Even if your current treatment is working well, we'll periodically reassess:

• Are your treatment goals being met?
• Has your MS activity level changed?
• Are there new therapies available that might be better?
• Have your life circumstances or priorities shifted?

Think of MS care as an ongoing conversation, not a one-time decision. You have a voice in your treatment throughout your journey.

Beyond Medications: A Holistic Approach to MS Care

While disease-modifying therapies are the foundation of MS treatment, they're not the whole picture. Living well with MS involves a comprehensive approach:

Lifestyle Factors That Support Treatment Success

Physical Activity: Regular exercise isn't just safe with MS – it's beneficial. Studies show that aerobic exercise and strength training can improve fatigue, mood, mobility, and overall quality of life. Even if your mobility is limited, there are adapted exercise programs that can help.

Nutrition: While there's no single "MS diet," eating a balanced, anti-inflammatory diet rich in fruits, vegetables, whole grains, and omega-3 fatty acids may support overall health. Some patients find that maintaining adequate vitamin D levels (easy to do in sunny Los Angeles) may play a role in MS management.

Stress Management: Chronic stress may trigger MS relapses in some people. Finding healthy ways to manage stress – whether through meditation, yoga, therapy, or other relaxation techniques – is an important part of your wellness plan.

Sleep: Quality sleep is essential for managing fatigue and supporting immune function. If you're struggling with sleep, let us know – there are strategies and treatments that can help.

Other Treatment Components

For Acute Relapses: High-dose corticosteroids (like IV methylprednisolone) are used to treat acute MS relapses, helping speed recovery from symptoms. These aren't daily medications but rather short courses given during flare-ups.

For Symptom Management: Beyond DMTs, there are many medications to help manage MS symptoms like spasticity, pain, bladder problems, fatigue, and mood changes. Managing these symptoms is an important part of maintaining your quality of life.

Rehabilitation Therapies: Physical therapy, occupational therapy, and cognitive rehabilitation can all play important roles in managing MS symptoms and maintaining function.

Mental and Emotional Health Matters

Living with a chronic illness affects your emotional wellbeing, and that's completely normal. Depression and anxiety are common in MS, and they're treatable. Don't hesitate to discuss your mental health with us or seek support from a therapist who understands chronic illness. Many of our Los Angeles-area patients also find value in MS support groups, where they can connect with others who truly understand what they're going through.

Looking Ahead: The Future of MS Treatment

The MS treatment landscape continues to evolve rapidly. Clinical trials are currently studying:

• Next-generation oral medications like BTK inhibitors
• Remyelination therapies that might help repair damaged myelin, not just prevent new damage
• Neuroprotection strategies to preserve nerve cells
• More precise biomarkers like NfL to guide treatment decisions

For patients with highly active MS who haven't responded to standard treatments, hematopoietic stem cell transplant (HSCT) is being studied at specialized centers with promising results.

The future of MS treatment is bright, and staying informed about emerging options ensures you can take advantage of advances as they become available.

Your Path Forward: Taking Control of Your MS

Choosing the right MS medication and knowing whether it's working are two of the most fundamental aspects of MS care. Armed with the knowledge in this guide, you're better equipped to:

• Understand the landscape of treatment options
• Participate actively in choosing a therapy that fits your life
• Know what markers to watch for to assess treatment success
• Feel confident that adjustments can be made if needed

Remember: being diagnosed with MS changes your life, but it doesn't define your life. With today's treatments and monitoring tools, many people with MS continue to work, travel, raise families, and pursue their passions.

At Achilles Neurology Clinic

Here in Beverly Hills and Los Angeles, we specialize in guiding patients through their MS journey from diagnosis onward. Whether you're a busy professional who needs a convenient treatment approach, a young parent concerned about family planning, or anyone seeking expert, personalized MS care, we're here to help.

We stay current with the latest research, FDA approvals, and monitoring tools (including emerging biomarkers like NfL testing) to ensure our patients have access to cutting-edge care. But we also understand that excellent MS treatment isn't just about prescribing the newest medication – it's about listening to your concerns, respecting your preferences, and developing a personalized plan that fits your life and goals.

Your Next Steps

If you're newly diagnosed or considering your treatment options:

1. Educate yourself (which you're already doing by reading this guide)
2. Write down your questions and priorities before your next appointment
3. Consider what matters most to you in a treatment
4. Have an open conversation with your neurologist about all available options
5. Get started – remember, early and effective treatment offers the best long-term outcomes
6. Stay engaged – monitoring your treatment through exams, MRIs, and potentially biomarker testing ensures you'll know it's working

You're Not Alone

Managing MS can feel isolating at times, but you're part of a large community. Millions of people worldwide are living with MS, and the research community is actively working on even better treatments.

Your future can be bright. With the right treatment strategy, good monitoring, and a healthcare team that listens, you can take control of your MS and live your fullest life.

At Achilles Neurology Clinic in Beverly Hills and Los Angeles, we're committed to providing expert, compassionate care for patients with multiple sclerosis and other neurological conditions. If you have questions about MS diagnosis, treatment options, or monitoring tools like NfL testing, or would like to schedule a consultation, please reach out to our office. We're here to help you navigate your MS journey with confidence.

About the Author

Dr. Achillefs Ntranos MD

Board-Certified Neurologist
Achilles Neurology Clinic

Dr. Achillefs Ntranos MD is a board-certified neurologist and MS specialist known for his thorough evaluations and compassionate approach. Originally from Greece, he trained at Johns Hopkins University and Mount Sinai Hospital before founding Achilles Neurology Clinic in Beverly Hills to deliver comprehensive, patient-centered neurological care. He specializes in MS, autoimmune neurology, neuropathy, headaches, and other neurological disorders, blending research-driven insights with personalized treatment plans.

Learn More About Dr. Ntranos(310) 774-7025

The information in this guide is for educational purposes and should not replace individualized medical advice. Always consult with your healthcare provider about your specific situation and treatment options.