Progressive Symptoms

For pts with SPMS who continue to experience relapses, treatment with one of the IFNs is reasonable; however, the IFNs are ineffective against purely progressive MS symptoms.
Mitoxantrone is approved in the United States for treatment of SPMS; however, this is not the population studied in the pivotal trial, evidence for efficacy is relatively weak, and leukemia risk as well as dose-related cardiac toxicity are important concerns.
Methotrexate (7.5-20 mg PO once each week) or azathioprine (2-3 mg/kg per day PO) is sometimes tried.
Pulse therapy with cyclophosphamide is employed in some centers for young adults with aggressive forms of MS.
Other smaller studies have examined monthly pulses of IV immunoglobulin (IVIg) or IV methylprednisolone.
For pts with PPMS, symptomatic therapy only is recommended, although a preplanned secondary analysis of a negative rituximab trial was promising and a follow-up trial with a related agent (ocrelizumab) is ongoing.