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Multiple Sclerosis - Treatment


Treatment for multiple sclerosis varies. The goals of treatment are to improve the quality of life by relieving symptoms caused by exacerbations (called palliative treatment), slowing the course of the disease as much as possible, and providing psychological support.

In general, starting treatment early in the course of the disease and continuing treatment indefinitely is thought to provide the most benefit. Health care providers and patients should make treatment decisions together.

Palliative Treatment 
Corticosteroids are typically prescribed to treat exacerbations of MS. Methylprednisolone (Solu-Medrol®) is be administered through an IV (intravenously) for 2–7 days, followed by a course of prednisone. Prednisone (Deltasone®) may be given for 10 days then the dosage is gradually reduced over 3 weeks and stopped.

Corticosteroids are usually well tolerated. Side effects include the following:


  • Heart failure
  • High blood pressure (hypertension)
  • High blood sugar levels (hyperglycemia)
  • High or low levels of sodium in the blood (hyper- or hyponatremia)
  • Increased risk for infection
  • Low level of potassium in the blood (hypokalemia)
  • Personality changes (e.g., mood swings)
  • Stomach ulcer
  • Swelling (edema) caused by fluid retention


Treatment for specific symptoms may include the following:


Muscle weakness, numbness, and stiffness (spasticity) may be treated using medication taken regularly or as needed. These drugs include muscle relaxants, such as tizanidine (Zanaflex®) and baclofen (Loresal®), benzodiazepines, such as diazepam (Valium®), and anticonvulsants, such as carbamazepine (Tegretol®).
Side effects of baclofen and tizanidine include drowsiness, dizziness, and fatigue. These drugs should not be discontinued abruptly. Carbamazepine may cause severe side effects including aplastic anemia, low white blood cell count (leukopenia), cancer that develops in cells found in blood and lymph (lymphoma), heart failure, and seizures.
Fatigue may be treated using amantadine hydrochloride (Symmetrel®) or modafinil (Provigil®) when frequent napping, adequate sleep at night, and daily exercise do not help. Side effects include nausea, dizziness, and headache.
Balance and equilibrium abnormalities (e.g., difficulty walking, uncoordinated movements, tremor) may be treated using medications such as benzodiazepines (Valium®), clonazepam (Klonopin®), propranolol (Inderal®), and mysoline (Primidone®). Side effects include drowsiness, confusion, and depression.
Bladder dysfunction (e.g., incontinence, nocturia) may be treated using medications such as oxybutynin (Ditropan®), tolterodine (Detrol®), and hyosciarnine (Levsin®). Bladder-emptying regimen, intermittent catheterization, and surgery may also be used. Side effects of medication include headache, dry mouth, constipation, and dizziness.
Constipation may be worsened by inactivity. Treatment includes eating a high-fiber diet, increasing fluid intake, daily exercise, and stool softeners. Rectal suppositories or enemas occasionally may be required.
Sexual dysfunction may occur in men and women with MS. Treatment is available for erectile dysfunction and female sexual dysfunction.

Immune Therapy

These treatments involve the use of medications that modify (change) the immune system's attack on the central nervous system. Immune therapy may reduce the frequency of exacerbations and the accumulation of damage.

These disease-modifying therapies include the following medications:


avonex

Interferon beta-1a (Avonex®)
is given intomuscle (intramuscular injection) once per week and has been shown to reduce exacerbations and physical disability. Side effects include flu-like symptoms (e.g., malaise, muscle aches, fever) and inflammation (i.e., pain, redness, infection) at the injection site.



rebif

Rebif® is an interferon beta-1a that has been shown to delay progression of MS and reduce the frequency of exacerbations. It is administered subcutaneously (under the skin), 3 times per week at a dose of 22 or 44 mcg and dosing frequency maintains a constant concentration of drug in the body.

Rebif is packaged in pre-measured, pre-filled syringes, which may be helpful for patients who have difficulty preparing medication for injection. Side effects include fatigue, inflammation at the injection site, headache, and flu-like symptoms.

betaseron

Interferon beta-1b (Betaseron®) is given by subcutaneous (under the skin) injection, every other day. It has been shown to reduce the frequency and severity of exacerbations. Side effects include flu-like symptoms (most common during the first few months of use) and inflammation at the injection site.


copaxone 

(Copaxone®)
is an amino acid that modifies actions of the immune system that may affect the progression of MS. It has been shown to reduce the frequency of exacerbations and the level of disability. It is given by subcutaneous injection every day and usually is well tolerated. Side effects include chest tightness and palpitations (rapid heart beat).

Tysabri






Tysabri (Natalizumab)

is an antibody thought to inhibit white blood cells from getting into the brain and attacking nerves. Keeping these cells from attacking nerves is believed to result in fewer lesions that cause multiple sclerosis symptoms.Tysabri has been shown to slow the worsening of physical disability and lower the frequency of flare-ups.  This medication may also reduce the number of new newly active lesions.  There are risks associated with this medication that must be discussed with your doctor.

Fingolimod





Fingolimod (Gilenya)

is an immunosuppressive drug approved for treating multiple sclerosis in 2010.  While all current MS drugs must be administered by injection or infusion, this is the first MS drug that is taken orally and may make a huge difference in the quality of life for MS patients.

According to one clinical trial, 70% of multiple sclerosis patients were relapse free after three years of daily treatment.  While clinical trials are ongoing, this medication may be a huge step forward in the treatment of MS with minimal side effects.

Psychotherapy

The central nervous system abnormalities associated with MS and the psychological and social impact of the disorder often result in mood swings and depression. MS support groups, counseling, and/or antidepressants (e.g., amitriptyline, clomipramine, nortriptyline) may be helpful.

Rehabilitation

Treatment for MS may also include physical therapy, occupational therapy, and speech therapy. Physical therapy uses exercises to help strengthen muscles, reduce pain and spasticity, and improve balance and walking. Assistive devices (e.g., canes, braces, walkers) may be used to help patients remain as independent as possible.

Occupational therapy increases independent function in activities of daily living that focus on grooming, dressing, eating, driving, and handwriting. Adaptations in the work and home environment (e.g., shower chairs, hand rails, ramps) are based on patient needs.
Speech therapy may be helpful if slurred speech (dysarthria) or difficulty swallowing (dysphagia) develops.

Prognosis

Most people with MS have a relatively normal life span and life expectancy is about 35 years after onset. After 25 years, approximately two-thirds of patients remain mobile. The disorder eventually results in physical limitations in about 70% of patients.

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