Treatment of Multiple Sclerosis
In 2003, the National Institute for Clinical Excellence (NICE) produced best practice guidance for the health care management of MS as a complex disorder that affects individuals and their carers in many and varied ways. NICE commented that the variability of MS and little evidence upon which to base recommendations made it hard to plan a cohesive or effective NHS primary or secondary service. The key recommendations from the NICE report are provided in the link at the bottom of the page.
No treatment for multiple sclerosis is uniformly effective, and there is currently no completely convincing evidence that any therapeutic agent significantly alters the outcome.
Because the progression and symptoms of the disease is highly variable, it is impossible to prescribe one type of treatment and prolonged periods of remission normally require no explicit medical treatment.
Generally a multidisciplinary approach is employed that includes the use of drugs with physical and psychological treatments that aim to control symptoms, treat relapses and modify the disease process.
Essentially two pharmacological approaches are used in addition to other interventions such as physiotherapy:
- Treatment of relapses.
- Treatment to modify the progress of MS – using ‘disease modifying’ drugs.
Relapses/Acute attacks
Relapses that produce objective impairments sufficient to impair function (e.g., loss of vision, strength, sensation or coordination and impaired gait) are treated with brief courses of corticosteroids. Several preparations of steroids exist, and the recent trend has been away from oral prednisolone to more potent preparations such as methylprednisolone given by the intravenous route.
Patients are usually not admitted to hospital for this therapy unless severe impairment is present but they do need to visit the hospital as day patients since intravenous steroid treatment is not often provided by GPs.
Disease modifying treatments
Since the mid-1990s new drugs have been shown by large randomised clinical trials to reduce the number and severity of relapses, reduce the number of new lesions appearing on magnetic resonance imaging and probably reduce long term progression of multiple sclerosis, although this has not yet been reliably confirmed.
The primary aim in using disease modifying drugs is therefore to prevent relapses and progressive demyelination with axonal loss and nerve cell death once a diagnosis of MS is confirmed.
A large range of drugs and other interventions have been investigated including, cytotoxics, immunosuppressants, antiviral agents, hyperbaric oxygen and the long term use of steroids.
Two treatments, Beta interferons and glatiramer acetate have been shown to reduce relapse rate by around a third.
Within two years some people develop antibodies to interferon which reduces its effectiveness. If antibodies do occur patients can be switched to treatment with glatiramer acetate.
There are four main disease modifying drugs licensed in the UK -:
- Avonex (beta interferon 1a),
- Rebif (beta interferon 1a),
- Betaferon(beta interferon 1b),
- Copaxone (glatiramer acetate).
A fifth drug, natalizumab (Tysabri) is also available on the NHS for people with ‘highly active relapsing remitting MS’.
Unfortunately, research has not shown any benefit of these drugs for people with primary progressive MS. It’s important to remember that they are not a cure for MS and it is not yet known whether they slow down the rate of progression of someone’s MS in the long term.
In addition to various drug treatments regular exercise is recommended even for patients with advanced multiple sclerosis, because it conditions the muscles, reduces spasticity, prevents contractures and has psychological benefits. Patients should therefore maintain normal activities where possible, but should avoid overwork, fatigue and exposure to excessive heat.
The overall goals of treatment include shortening acute exacerbations and hastening recovery from relapses, decreasing frequency of exacerbations and relieving symptoms; maintaining independent mobility including a patient's ability to walk is particularly important.
Symptomatic management
Multiple sclerosis can produce an array of symptoms, many of which can be managed if not cured. However, it can take some time to find the best treatments for each person. Bladder frequency and urgency may respond well to oxybutynin. Pain and spasms from spastic limbs can respond well to baclofen. Emotional lability with pathological laughing or crying can be managed with a tricyclic antidepressant. Neurological pain, sexual dysfunction, weakness, sensory symptoms, tremor, ataxia and cognitive change, can all be difficult to manage, but even these may respond to various therapeutic approaches. It is important for health care professionals to recognise that half of patients with multiple sclerosis will become depressed and that therapy and counselling may be necessary.
A wide range of drugs, in addition to those indicated previously are used to treat these symptoms. For details see the link at the bottom of the page.
Click on the links for details of:
Amended April 2008
