What is Multiple Sclerosis?
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Multiple sclerosis is a complex disease of the central nervous system (brain, spinal cord, and optic nerves) characterized by relapses (neurologic symptoms which appear rapidly but often improve over weeks or months), remissions and often progression of disability over time. MS is currently not a curable disease.
MS is thought to be an immune-mediated disease, meaning that errors in the function of the immune system cause damage in the central nervous system. The immune system functions to protect the body from various environmental hazards or pathogens such as viruses, bacteria and fungi. The immune system is very sophisticated and has regulatory mechanisms in place that prevent it from recognizing body tissues as a pathogen.
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In an immune-mediated disease such as MS, these regulatory mechanisms are disrupted and the ability to ignore itself is lost. In MS, the immune system recognizes tissue within the central nervous system as a pathogen and therefore causes inflammation and damage.
MRI of the Brain following gadolinium demonstrating enhancement of MS lesions
MS is diagnosed based on the patient’s history of symptoms (if they can be referred to the central nervous system) over time, the neurological examination, and imaging tests such as brain and/or spinal cord MRI. Sometimes other tests are used like evoked potentials, optical coherence tomography, and/or a spinal tap.
Blood tests are also used to make sure the symptoms are not caused by something other than MS. As there is no single test for MS, the diagnosis is made by summing together the history, neurological exam, MRI and other test findings and the exclusion of other illnesses.
Symptoms of MS vary among individuals but often include:
- Numbness or tingling in the limbs
- Impaired balance
- Change in vision such as blurred vision in one eye or double vision
- Change in bowel, bladder and sexual function
- Stiffness or tightness in the muscles
- Trouble walking
Approximately 85% of patients begin the disease with relapsing-remitting MS. These patients experience episodic relapses (sometimes called flares, attacks or exacerbations) in which they experience the onset of symptoms over a few days or weeks, with gradual recovery over time, whether complete or incomplete.
Inflammatory changes on MRI are the hallmark of the relapsing phase of the disease. During the relapsing phase of the disease there is frequent gadolinium enhancement seen on MRI (areas on the MRI scan that show up as bright spots after injection of the contrast dye), which indicates areas of active inflammation. Gadolinium enhancement occurs about 5-10 times more frequently than clinical relapses.
Over time, some patients will experience less inflammatory changes and more of a slow, progressive worsening of multiple symptoms and disability, often termed “progression.” This is classified as secondary-progressive MS. Over time there can also be a decrease in brain volume. Approximately 15% of patients never have relapses; rather their disease is characterized by a progression of symptoms over time from the time of onset. This disease course is known as primary-progressive MS.
Management of MS is approached on three fronts: treatment of relapses, disease modification and symptom management.
A relapse is defined as new or worsening neurological symptoms that last longer than 24 hours. Relapses usually evolve over 1-7 days. Their intensity may plateau for several weeks and resolve to some degree over weeks to several months.
The usual treatment of a relapse is high-dose anti-inflammatory steroids given by mouth or intravenous infusion. This is the same type of steroid used for allergic reactions, like with poison ivy.
Although there is little evidence that high-dose steroids have a long-term benefit in MS, they are believed to hasten recovery from relapse symptoms. Commonly, steroids are given in a vein for MS relapses. Many physicians give 1 gm of methylprednisolone over 1-2 hours for 3-5 consecutive days. There are oral equivalents (i.e. prednisone or oral methylprednisolone) that can be used instead.
Recent exposure to excessive heat or a recent increase in activity may cause symptoms to worsen or return, and can cause people feel like they are having a new relapse. Infections (and their resultant fevers) can also make symptoms temporarily worse. These events, sometimes called pseudo-relapses, typically do not require treatment because resolution of the underlying infection or the patient leaving the source of heat will resolve the issue.
Disease modifying medications for multiple sclerosis
Prior to 1993, there were no FDA-approved medications for the treatment of multiple sclerosis that could alter the natural history of the disease. Since that time, there have been many medications approved for multiple sclerosis. These medications have been shown to reduce the chance of future relapses, MRI activity, and disability worsening.
- Interferon beta-1b: Betaseron®, EXTAVIA®
- Glatiramer acetate: Copaxone®
- Interferon beta-1a: Avonex®, Rebif®
- Peginterferon beta-1a: PLEGRIDY®
- Daclizumab: ZINBRYTA®
- Fingolimod: Gilenya®
- Dimethyl fumarate: Tecfidera®
- Teriflunomide: AUBAGIO®
- Natalizumab: Tysabri®
- Alemtuzumab: LEMTRADA®
- Mitoxantrone: Novantrone®
These options all have different efficacy rates, delivery systems and side-effect profiles. It is important to discuss these options with your physician to make the best decision for each individual patient.
Supplementation with vitamin D likely also has a disease-modifying effect, as vitamin D supplementation is demonstrated to reduce MRI activity in MS and low vitamin D levels are associated with higher relapse rates. For these reasons, your neurologist will likely advise vitamin D supplements to complement your disease-modifying therapy choice.
Symptomatic treatments for multiple sclerosis
The disease-modifying therapies listed above can treat the disease itself, but they do not treat existing symptoms. Thankfully there are numerous medications that can be prescribed for symptoms such as pain, spasticity, walking difficulties, fatigue, depression, etc. You should work with your doctor to determine the most appropriate medications to alleviate your symptoms.
In addition to medications, there are numerous non-pharmaceutical approaches to help alleviate the symptoms of MS. These include physical, occupational, speech, and cognitive therapy and rehabilitation approaches, acupuncture, yoga, meditation and relaxation techniques, talk therapy and support groups.