Most people with MS end up on a lot of medication. Mostly prescription.
And the wild part is that many of us weren't "pill people" before diagnosis. Maybe the occasional over-the-counter painkiller for a headache, if that. Then MS shows up and suddenly you're swallowing a handful of pills every day just to function like a recognizable human being. That's not even treating MS itself — that's just managing symptoms well enough to get through the day.
Treating the actual disease is a different story. And even the word treat feels generous, because MS isn't a treat—and it sure as hell isn't fixable — yet. However, what we can do is slow it down — reduce the chances of new damage forming. That's where disease-modifying therapies (DMTs) come in.
For many of us, choosing a DMT means deciding how aggressively we want to slow disease activity and progression. The options range from pills, to daily or monthly injections, to infusions — or, for some people at some points, choosing to do nothing at all.
That decision usually comes down to a mix of factors: what you're willing to take, potential side effects, how the medication fits into your life, and how much risk you're comfortable carrying. There's no universal right answer — just tradeoffs
Disease-Modifying Therapies (DMTs)
Disease-modifying therapies aren't about fixing MS — because we can't do that yet. They're about slowing it down. Specifically, reducing relapse activity and lowering the odds of new damage forming over time.
DMTs come in a few broad flavors: pills, injections, and infusions. Some are considered lower-efficacy with fewer risks. Others are more aggressive and aim to shut down specific parts of the immune system more decisively.
There's no universally "right" choice. For most of us, it comes down to a tradeoff between:
- how aggressive we want to be
- how much risk we're comfortable carrying
- how the medication fits into our actual lives
Below is a high-level look at the major DMT categories — not a recommendation, just context.
| DMT |
Class |
How It Works (High Level) |
How Taken |
| Copaxone |
Injectables |
Immune decoy / immune modulation |
Injection |
| Interferons |
Injectables |
Modulates immune signaling |
Injection |
| Gilenya / Ponvory / Zeposia |
Oral |
Traps immune cells in lymph nodes |
Pill |
| Tecfidera / Vumerity |
Oral |
Reduces inflammatory immune activity |
Pill |
| Briumvi |
CD20 Inhibitor |
Depletes circulating B-cells |
Infusion |
| Kesimpta |
CD20 Inhibitor |
Depletes circulating B-cells |
Injection |
| Ocrevus |
CD20 Inhibitor |
Depletes circulating B-cells |
Infusion |
| Ocrevus Zunovo |
CD20 Inhibitor |
Depletes circulating B-cells |
Injection |
A Closer Look at One Common Approach - CD20 Inhibitors
From here on, this post focuses on one specific group of MS treatments — not because they're "better," but because they're common, effective, and come with experiences people often don't hear explained very well.
These treatments work by targeting B-cells, a part of the immune system that plays a role in MS inflammation.
They don't permanently wipe out your immune system. They temporarily reduce circulating B-cells, which helps lower inflammatory activity. Over time, new B-cells are produced, which is why treatment is repeated on a schedule.
Across clinical trials, therapies in this group show around a ~52% average reduction in relapse activity compared to older medications.
Disclaimer: ~52% comes from averaging clinical trial relapse reductions, not from vibes or promises. The comparison drugs weren’t the same in every study, and biology does whatever it wants anyway. Math was involved. No refunds.
For many people, that level of risk reduction is enough to justify going this route — especially when the alternative is letting MS run unchecked.
What This Means in Real Life
Once you start one of these therapies, the goal is to keep B-cell levels low enough that they're less likely to contribute to MS activity.
But B-cells don't stay gone forever. Your body keeps making new ones. That timing — how fast they come back, how your body reacts, and how close you are to your next dose — is where lived experience starts to matter more than pamphlets.
Below are the most commonly used options in this category.
How it works
Briumvi targets CD20-positive B-cells and promotes rapid depletion of those cells from circulation.
What this means in practice
Briumvi tags problematic B-cells and lets your immune system handle the eviction.
The drug doesn’t stick around—it’s gone within weeks—but the impact lasts until your body slowly churns out new B-cells.
They’re still morons who can’t read the manual, so the six-month infusion cycle is designed to step back in before they can organize and start causing damage.
How it's given
Briumvi is given by IV infusion every six months. You’ll usually get pre-meds like steroids and Benadryl ahead of time to help your body tolerate the infusion and reduce reactions.
Time Commitment
On-boarding dose: the medication itself is given in a low dose over four hours. Between setup, pre-meds, infusion and monitoring, plan on 5-6 hours.
Standard dose: the medication itself is given over a one hour period. Between setup, pre-meds, infusion and monitoring, plan on 1.5-2 hours.
Common Side Effects
Upper respiratory tract infections
(e.g., common cold, sinusitis, sore throat)
Lower respiratory tract infections
(e.g., bronchitis, pneumonia)
Herpes virus-associated infections
(e.g., cold sores)
Pain in extremities
Insomnia
Fatigue
Crap Gap a few weeks prior and until the next infusion.
Rare but serious Side effects
Infusion Reactions
(fever, chills, headache, fast heart beat, hives, itching, dizziness, nausea, trouble breathing, swelling of the face/tongue/throat)
Low antibodies
Serious infections
Hepatitis B virus reactivation
(if you've had HBV in the past)
JC virus reactivation
(leading to PML - Progressive Multifocal Leukoencephalopathy)
Liver damage
Fetal harm
(contraception is advised during treatment and for several months after the last dose)
Not everyone experiences these side effects, and many people experience few or none. If you have any serious side effects, seek medical assistance immediately.
Efficacy
Clinical trials showed roughly 49–59% relapse reduction compared to older MS therapy (teriflunomide).
How it works
Kesimpta targets CD20-positive B-cells and tags them so your immune system removes them from circulation.
What this means in practice
Kesimpta keeps problematic B-cells suppressed using smaller, more frequent doses instead of a single big hit.
Rather than wiping the slate every six months and waiting for cells to rebuild, it aims for steady, ongoing control.
The goal is fewer peaks, fewer valleys, and less opportunity for B-cells to regroup and start causing damage in the first place
How it's given
Self-injection pen, at home. No infusion center required.
Time Commitment
A few minutes per month.
Loading phase: one injection weekly for 3 weeks, followed by a short break.
Maintenance phase: one injection every month to keep B-cells consistently suppressed.
Common Side Effects
Injection site reactions
(e.g., pain, redness, swelling, itching or bruising at the injection area)
Injection-related reactions
(e.g., fever, chills, fatigure, headache, muscle ache, sore throat)
Upper respitory track infections
(e.g., common cold, sinusitis, sore throat)
Urinary track infections (UTIs)
Headache
Crap Gap a few day prior to next injection
Rare but serious Side effects
Serious infections
Hepatitis B virus reactivation
(if you've had HBV in the past)
JC virus reactivation
(leading to PML - Progressive Multifocal Leukoencephalopathy)
Low antibodies
Injection Reactions
(e.g.. anaphylaxis, throat swelling, difficulty breathing, skin rash, itching, flushing, facial swelling)
Fetal Harm
(Most providers may require contraceptive 6 months prior and 6 months post using Kesimpta. Discuss with your medical team.)
Not everyone experiences these side effects, and many people experience few or none. If you have any serious side effects, seek medical assistance immediately.
Efficacy
Clinical trials showed 51–58% relapse reduction compared to older MS therapy (teriflunomide).
How it works
One of the most widely used infusion-based MS treatments, Ocrevus targets CD20-positive B-cells and tags them so your immune system removes them from circulation.
Ocrevus has two different versions (Ocrevus and Ocrevus Zunovo). The main difference is how they are administered (IV vs Subcutaneous Injection).
What this means in practice
Ocrevus delivers a strong depletion of problematic B-cells through an infusion, then relies on time between doses while your immune system slowly rebuilds them. The medication itself doesn’t hang around long-term, but the immune effects do.
The six-month dosing schedule is designed to step back in before B-cells fully repopulate and have a chance to ramp up inflammation and cause more damage.
How it's given
Ocrevus is given by IV infusion every six months. You’ll usually get pre-meds like steroids and antihistamines and acetaminophen ahead of time to help your body tolerate the infusion and reduce reactions.
Ocrevus Zunovo is given by subcutaneous injection into your abdomen area, usually in a clinic setting. Its formulation delivers enough medication up front that treatment starts on a standard six-month schedule, not requiring a loading dose. Pre-meds depend on your perscribing provider.
Time Commitment
Ocrevus
Loading dose: 300mg administered over a 2.5-3.5 hour period. Second does of 300mg given 14 days later over the same time period. Plan on spending 4-6 hours there.
Standard dose: after the loading doses, every six months plan on spending 4-6 hours in the infusion center or hospital.
Ocrevus Zunovo
While the medication itself can be delivered relatively quickly, some clinicians intentionally administer it over a 30-60 min period—to improve tolerability and reduce injection-site reactions. Plan on 1-1.5 hours.
Common Side Effects
Upper respiratory tract infections
(e.g., common cold, sinusitis, sore throat)
Lower respiratory tract infections
(e.g., bronchitis, pneumonia)
Herpes virus-associated infections
(e.g., cold sores)
Pain in extremities
Insomnia
Fatigue
Swelling
Back pain
Depression
Digestive issues
Crap Gap a few weeks prior and until the next infusion.
Rare but serious Side effects
Infusion Reactions
(fever, chills, headache, fast heart beat, hives, itching, dizziness, nausea, trouble breathing, swelling of the face/tongue/throat)
Low antibodies
Serious infections, wounds that won't heal
Hepatitis B virus reactivation
(if you've had HBV in the past)
JC virus reactivation
(leading to PML - Progressive Multifocal Leukoencephalopathy)
Liver problems
(upper right belly pain, dark urine, yellow skin/eyes, severe fatigue)
Sudden severe stomach pain or bloody diarrhea
Breast changes
(lumps, redness, pain, nipple discharge)
Fetal harm
(contraception is advised during treatment and for several months after the last dose)
Not everyone experiences these side effects, and many people experience few or none. If you have any serious side effects, seek medical assistance immediately.
Efficacy
In the OPERA I and OPERA II phase 3 trials (relapsing MS), Ocrevus lowered the annualized relapse rate by about 46–47% compared to interferon beta-1a (Rebif).
Clinical Trial Details
OPERA I & II - Full Paper
Ocrelizumab versus Interferon Beta-1a in Relapsing Multiple Sclerosis - Read on PubMed or Read on New England Journal of Medicine
This publication reports the phase III OPERA I & II trials, showing that ocrelizumab was associated with significantly lower annualized relapse rates and reduced MRI disease activity compared with interferon beta-1a in people with relapsing MS.
OCARINA II Trial
Subcutaneous Ocrelizumab (Zunovo) Pharmacokinetic Bridging Study
This publication reports the phase III OCARINA II study, showing that subcutaneous ocrelizumab (Zunovo) achieves comparable drug exposure and B-cell depletion to IV Ocrevus in people with relapsing MS.
OCARINA II: Subcutaneous OcrelizumabSubcutaneous Ocrelizumab in Patients With Multiple Sclerosis
This study did not re-measure relapse reduction directly. Instead, it demonstrated that Zunovo delivers equivalent pharmacokinetics and immune effects to IV Ocrevus, allowing efficacy to be inferred from the OPERA I & II trials.
What is "The Crap Gap"?
Crap Gap is a term many people with MS use to describe the period when B-cells begin returning as the effects of a CD20 treatment wear off — and your immune and nervous systems decide to be dramatic about it.
During this window, some people notice their existing symptoms becoming more noticeable or amped up. That can look like heavier fatigue than usual, achy joints, increased pain, brain fog, or just an overall feeling of being completely wiped out. A lot of people describe it as having the flu without the sore throat — you feel awful, but nothing obvious is "wrong."
Not everyone experiences Crap Gap, and it doesn't show up the same way for everyone. But it's common enough that patients noticed the pattern, named it, and started talking (and yes, bitching) about it — which is pretty warranted considering the amount of bullshit MS already makes us deal with.
Final Note
This post started as a Crap Gap rant—because I'm in one right now (next infusion is six days out, and yes, I'm counting). But while I was pulling together details on these drugs, I realized this is the information I wish I'd been given when I was first diagnosed.
Instead, the experience went like this:
"You have MS." Then a stack of glossy drug pamphlets gets shoved into my hands, followed by
"Go home and pick one if you want and let me know." No explanation of what any of them actually do. No context. No tradeoffs. Just… homework.
My entire ride home was spent thinking,
"Cool. MS—just like I expected—but now I need to fire this neurologist." Because I'm not paying a specialist to assign me a research project they should be able to explain in plain English. If I wanted to crowdsource my medical care, I could've skipped the appointment and gone straight to Google.
My current neurologist is great, though. Sometimes you have to break a few eggs to find the right one.
So I did what a lot of us end up doing anyway—I became my own research department. I dug through clinical trials, FDA labels, forums, and patient experiences trying to figure out which of these drugs made sense for me. And even then, most of what's out there is numbers and charts. Not reality. Not lived experience. Not the part where you're asking, "Okay, but how wrecked am I going to feel after this?"
This spiraled into more than planned, so it's now a multi-part series. Each post will cover a different DMT category, with a final post pulling everything together into one place. Not recommendations. Not cheerleading. Just explanations that don't assume you have a medical degree or unlimited patience.
For now, this is one slice of the MS treatment landscape—
explained like a human.
Because apparently that's asking too much.
