MULTIPLE SCLEROSIS TREATMENT

The multiple sclerosis treatment depends on the patient’s clinical condition and the course of the disease.

Based on current knowledge and experience, we can list 4 mains directions in the MS management:

  1. Treating the attacks of the disease [may also be referred to as symptomatic treatment]

    Used mainly in relapsing-remitting MS patients. This treatment can be applied under the condition that an attack has been diagnosed (i.e. the onset of new or exacerbation of existing neurological symptoms, which lead to deterioration of the patient’s condition by at least 1 step on the EDSS scale, persist for at least 24 hours, and are not infection-related).

    It is critical to rule out infection before commencing the therapy, as it may influence the patient’s neurological condition by imitating an attack. Also, administering glucocorticosteroids to a patient with an ongoing infection is a serious threat to the patient’s health and life.

    Glucocorticoids have been found to have a short-term - but still beneficial - effect on the rate of the patient’s functional recovery. Studies do not favour any particular drug, dosage or method of administration, but experiments show that the most commonly applied drug is methylprednisolone at a dose of 1g five times per day, intravenously via infusion pump.

    The patient’s condition should be monitored during treatment, as glucocorticosteroid therapy is linked with many side effects.
    If serious side effects occur or an infection becomes apparent during the therapy, the attending physician should review the indications and, if necessary, discontinue the treatment.

  2. Symptomatic treatment

    Symptomatic treatment usually does not differ significantly from therapeutic management used in situations where the given symptom is caused by a condition other than MS. The decision is usually made by the attending physician based on the patient’s complaints, their medical history and overall condition.

    The most common complaints reported by patients include: spasticity, tremor, pain, dysphoria (depression), chronic fatigue, lower urinary tract dysfunction, sexual dysfunction.

    Apart from pharmacotherapy, symptomatic treatment also involves physiotherapy and psychotherapy; the assistance given to the patient needs to be comprehensive, as one form of therapy is often insufficient.

  3. Immunomodulatory treatment

    This type of treatment involves drugs modifying the natural course of the disease (DMD – disease-modifying drugs). Currently, all drugs within this group are being tested for their effectiveness in different groups of patients, as well as for their long-term effects. DMDs include interferon beta, glatiramer acetate, mitoxantrone, and natalizumab.

    • Interferon beta – inhibits inflammatory reactions, limits the influence of proinflammatory cytokines and lymphocyte migration. There are two types of interferon beta: interferon beta 1a (2 drugs) and interferon beta 1b (2 drugs), which differ in dose, as well as method and frequency of administration. These drugs may reduce the number of attacks. Interferons are indicated for the treatment of the relapsing-remitting subtype of multiple sclerosis, and some of them also for the secondary progressive type in the active stage confirmed by attacks. The patients included in the treatment programme are those who have experienced at least two attacks over 2 to 3 years. The patients who usually do not qualify for interferon treatment are those at a very advanced stage of the disease, making it impossible to move (EDSS<5). The therapy aims at reducing the number of attacks, but it has also been reported to decrease the number of lesions in an MRI scan.
    • Glatiramer acetate – its mechanism of action involves stimulating regulatory lymphocytes, which inhibit autoimmunological reactions. It is used mainly in patients with the relapsing-remitting subtype of the disease. (The best treatment results were obtained in patients with a relatively early stage of MS – EDSS 0-2). The therapy aims at reducing the number of attacks and the number of lesions in an MRI scan.
    • Mitoxantrone – this is a cytostatic drug. In the trials conducted, this drug has had most beneficial effects in patients with the secondary progressive subtype. It is currently indicated at a dose of 12mg/m2, administered intravenously once every 3 months, repeated for a maximum of 6 times (it is possible to administer two extra infusions with a dose reduced by half). Mitoxantrone influences the number of attacks, but does not influence the number of lesions in an MRI scan. The drug has strong cardiotoxic effects (the dose of 140mg must not be exceeded over a patient’s lifetime).
    • Natalizumab – is a new, strong drug, with a novel mechanism of action, used in the treatment of multiple sclerosis. It prevents autoreactive lymphocytes from passing from blood into the brain, thus blocking the development of the disease. Natalizumab speeds up regeneration and stabilization of myelin sheath lesions, which cause the symptoms of multiple sclerosis. The therapy aims at reducing the number of attacks and the number of lesions in MRI. Natalizumab therapy was the first one to reportedly stop the progression of some MS symptoms. Studies have also shown that using this drug eliminates fatigue and improves physical functionality, as well as the quality of life in some MS patients1. Natalizumab has been approved as monotherapy for the treatment of highly active relapsing-remitting MS in spite of prior treatment with beta interferon, as well as for the treatment of rapidly progressing, severe MS.

  4. Immunosuppressive treatment

    There are also other drugs, whose effectiveness has not been fully proved (few clinical trials, significant cytotoxicity, in most cases these constitute the so-called rescue therapies in case of significant deterioration of the patient's condition, their action is that of "suppressing" the immune system). These include: Cyclophosphamide, Methotrexate, Azathioprine, Cladribine, Ciclosporine.

    • Cyclophosphamide – the drug is an alternative to mitoxantrone (where the life-time dose is a limitation), currently it is mainly indicated for cases of sudden, significant deterioration of the patient’s condition.
    • Methotrexate – a cytostatic drug, disturbs DNA synthesis in cells promoting immunological response. It effectively slows down the progression of the disease and reduces the number of lesions in MRI.
    • Azathioprine – inhibits the synthesis of nucleic acids in lymphocytes. It has a mild but beneficial influence on the course of the disease (reduced number of attacks and the number lesions in MRI).
    • Cladribine – inhibits DNA synthesis in lymphocytes. The therapy aims at reducing the number of attacks and the number of lesions in MRI.
    • Ciclosporine – reduces the activity of CD4+ T cells by inhibiting IL-2. It is highly cytotoxic. It is not currently used to treat MS.

In patients affected by the primary progressive subtype, it has not yet been possible to find a drug with (evidenced) influence over the patients general and neurological condition. Currently, symptomatic treatment is being used in this patient group.

Over the long period of time filled with effective MS therapy search trials, many preparations have been used whose effectiveness has been proved to be more or less significant for the course of the disease. Some drugs have been withdrawn from clinical trials due to their high toxicity and significant side effects.
The recent, significant progress in MS management offers great promise for the future.

source: www.ptsr.org.pl