Understanding Multiple Sclerosis
The goals of treatment for multiple sclerosis are:
- Modify the disease course by reducing the number and severity of relapses (also called exacerbations or flares), reducing accumulation of lesions, and slowing the progression of disability
- Treat relapses on a short-term as-needed basis
- Manage symptoms
Patients are recommended to seek care from a neurologist experienced in treating multiple sclerosis.
Early Treatment. Evidence strongly suggests that the most destructive changes from multiple sclerosis in the brain occur very early on in the disease process -- and may cause considerable damage even before symptoms begin.
Many doctors recommend treatment after a first neurological episode of MS (a clinically isolated syndrome) using disease-modifying drugs. The best current approach is to use specific findings from MRI scans to determine patients at highest risk for progression, making them likely candidates for early treatment with these drugs.
Over a third of patients will progress even with immediate treatment, but without early treatment about 50% of patients will progress to clinically identifiable multiple sclerosis.
Treatment with Disease-Modifying Drugs
Six disease-modifying drugs are approved by the FDA for treatment of multiple sclerosis:
- Interferon beta-1b (Betaseron, Extavia). Given in subcutaneous (under the skin) injections every other day.
- Interferon beta-1a (Avonex). Given as weekly intramuscular injections.
- Interferon beta-1a (Rebif). Given in subcutaneous injections three times a week.
- Glatiramer acetate (Copaxone). Given daily in subcutaneous injections.
- Natalizumab (Tysabri). Given by intravenous infusion once every four weeks.
- Mitoxantrone (Novantrone). Given intravenously once every three months for 2 - 3 years at most.
Most of these drugs are taken on a long-term basis. They can help reduce disease activity and progression for relapse-remitting MS (the most common form of MS) and other types of MS that have relapses (secondary-progressive MS, progressive-relapsing MS.) At this time, there are no proven treatments for primary-progressive MS. Disease-modifying drugs can have significant side effects.
If disease-modifying drugs do not work, doctors may try other drugs that are not specifically approved for MS. They include intravenous immunoglobulin (IVIg), methotrexate, azathrioprine (Imuran), and cyclophosphamide (Cytoxan).
Treating Acute Relapses
A relapse (also called exacerbation or flare-up) is an attack that brings about new symptoms or worsening of old symptoms. It is caused by inflammation in the central nervous system. Relapses can be mild or severe, and may last from a few days to several months.
Pseudoexacerbations are temporary worsening of symptoms that are usually caused by an external trigger, such as infection, heat, or stress. Pseudoexacerbations do not involve myelin inflammation and symptoms usually subside within 24 hours. To be considered a true relapse or exacerbation, symptoms and neurological signs must last at least 24 hours and occur at least 30 days after a previous attack.
Not all acute relapses require treatment. For attacks that are severe, a short course of high-dose corticosteroid drugs is the standard treatment. . Typically, intravenous methylprednisolone (IVMP) is given for 3 - 5 days. Sometimes this is followed by oral prednisolone for a few days. Long-term treatment with corticosteroids is not recommended. These drugs can cause serious side effects and do not have any effect on MS disease progression.
Other treatment options for relapses are injections of adrenocorticotropic hormone (ACTH) and plasmapheresis (plasma exchange). These treatments are usually reserved for a small percentage of patients with very severe symptoms who do not respond to steroid drugs.
MS symptoms are managed through a combination of treatment approaches that include medications, self-care, and physical and occupational therapy.
Drugs that are specifically approved for treating symptoms associated with MS include:
- Dalfampridine (Ampyra) is approved to improve walking in patients with MS. In clinical trials, patients treated with dalfampridine had faster walking speeds than patients who received placebo. Dalfampridine is taken as a pill.
- Onabotulinumtoxin A (Botox) is approved to treat upper limb spasticity in the flexor muscles of the elbow, wrist, and fingers. It is given by injection.
Oral Medications. Fingolimod and cladibrine, two new oral medications, are showing promise in late-stage clinical trials for reducing relapse rates in patients with MS.
Stem Cell Transplantation. Investigators are studying the benefits of stem cell transplantation procedures. Stem cells are produced in the bone marrow and are the early forms for all blood cells in the body (including red, white, and immune cells). Early studies indicate that stem cell transplantation may slow MS progression. Larger randomized controlled trials are currently under way.