- The etiology of multiple sclerosis (MS) is unknown, but it appears to be autoimmune in nature. Currently there is no cure.
- MS is characterized by CNS demyelination and axonal damage.
- MS is classified by the nature of progression over time into several categories, which have different clinical presentations and responses to therapy.
- Although studies do not support the general use of any of the FDA-approved disease-modifying therapies (DMTs) in patients with progressive forms of the illness, information derived from multiple studies suggests younger patients with progressive illness and those with either superimposed acute relapses or enhancing lesions on magnetic resonance imaging (MRI) scans may benefit from some of the presently used DMTs.
- Diagnosis of MS requires evidence of dissemination of lesions over time and in multiple parts of the CNS and/or optic nerve, and is made primarily on the basis of clinical symptoms and examination. Diagnostic criteria also allow for the use of MRI, spinal fluid evaluation, optical coherence tomography, and evoked potentials to aid in the diagnosis.
- Exacerbations or relapses of MS can be disabling. When this is the case exacerbations and relapses are treated with high-dose glucocorticoids, such as methylprednisolone IV, with onset of clinical response typically within 3 to 5 days.
- Treatment of relapsing-remitting multiple sclerosis (RRMS) with the DMTs interferon-β (IFN-β) (Avonex, Betaseron, Rebif, Extavia), glatiramer acetate (Copaxone), natalizumab (Tysabri), mitoxantrone (Novantrone), fingolimod (Gilenya), teriflunomide (Aubagio), and dimethyl fumarate (Tecfidera) can reduce annual relapse rate, lessen severity of relapses, slow progression of changes on MRI scans, slow progression of disability, and slow cognitive decline. In addition, they have been shown to reduce the likelihood of developing a second attack after a first clinically isolated syndrome (CIS) consistent with MS.
- In most cases, treatment with DMTs should begin promptly after the diagnosis of relapsing-remitting MS, or after a CIS if the brain MRI is suggestive of high risk of further attacks. Natalizumab and other choices that have been associated with problematic adverse events should be reserved for those patients who have failed one or more standard therapies and those with poor prognostic signs.
- The definition of treatment inadequacy for RRMS remains unclear, and therapy changes after “treatment failure” should be individualized.
- Patients suffering with MS frequently have symptoms such as spasticity, bladder dysfunction, fatigue, neuropathic pain, cognitive dysfunction, and depression that can require treatment. Patients must be counseled that therapies such as IFN-β and glatiramer acetate will not relieve these symptoms. Depression is common in MS and can pose the risk of suicide.
On completion of the chapter, the reader will be able to:
List four factors associated with the risk of developing multiple sclerosis (MS).
Describe the etiology of MS.
Discuss the pathophysiology of MS.
Explain the concept of T-cell differentiation and plasticity in MS.
Counsel a patient on the goals of medication therapy in MS.
Recommend treatment for a patient with an exacerbation of MS.
Define when it is appropriate to start ...