Multiple Sclerosis; Treatment
Before the 1990s there was no treatment that could alter the course of multiple sclerosis (MS). Steroids, which suppress the immune system, were used to treat exacerbations (when at least one symptom occurs, or worsens, for more than 24 hours, lasting for days, weeks, months or indefinitely), but long-term use of these drugs is ineffective and produces severe side effects.
The outlook brightened in 1993, with the introduction of Betaseron, the first disease-altering drug for relapsing-remitting MS. Two other medications, Avonex and Copaxone, followed in 1996. These three treatments, dubbed the “ABC drugs,” have revolutionized the way relapsing-remitting MS is treated. The ABC drugs do not stop MS entirely or cure it, but they do reduce the frequency and intensity of attacks and slow the progress of damage.
The ABC drugs do not stop MS entirely or cure it, but they do reduce the frequency and intensity of attacks and slow the progress of damage.
Betaseron (interferon beta-1b) and Avonex (interferon beta-1a) are biotechnology drugs based on a natural human protein that dampens immune system activity. The third disease-altering drug, Copaxone (glatiramer acetate), works by a different mechanism: it looks like myelin to the immune system and acts as a decoy. All three are injected drugs. Your health care professional will instruct you or a caregiver on medication preparation and self-injection.
In 2002, the U.S. Food and Drug Administration (FDA) approved a third form of interferon called Rebif. Like the ABC drugs, it is indicated for the treatment of patients with relapsing forms of MS to decrease the frequency of clinical exacerbations and delay the accumulation of physical disability. Like Avonex, Rebif is the beta-1a form of the human protein interferon. However, unlike Avonex’s once a week, intra-muscular injection regimen, Rebif is injected three times a week subcutaneously. It is now used as a first-line treatment, on par with the ABC drugs.
Additional information about Rebif is available from the manufacturer’s Web site.
Key facts about the ABC drugs:
Avonex is injected by deep intra-muscular injection once a week. Side effects include flu-like symptoms following the injection, which lessen over time. Rarer side effects include mild anemia and elevated liver enzymes, which may indicate liver inflammation.
Betaseron is injected every other day under the skin. Side effects include flu-like symptoms following injection, which lessen over time; and injection site reactions, about five percent of which need medical attention. Rarer side effects include elevated liver enzymes and low white-blood-cell counts, which make a person susceptible to infection.
Copaxone is injected daily. Injection site reactions are the most common side effects. Other, rarer side effects include a reaction immediately after injection that includes anxiety, chest tightness, shortness of breath and flushing; this lasts a few minutes and has no known long-term effects.
Note: Talk to your health care provider if you experience side effects from one of the ABC drugs. There may be strategies you can use to minimize the side effects, they may abate in a few months, or you may be able to switch to one of the other two drugs and avoid the side effects. If you stop taking the drug, it may seem like there are no consequences, but MS damage can occur steadily and silently for long periods before the next attack.
Other treatments for MS:
In November 2004, the FDA approved a new biologic treatment called natalizumab (Tysabri). It is a monoclonal antibody bioengineered from part of a mouse antibody to closely resemble a human antibody and is approved for patients with relapsing forms of the disease to reduce the frequency of symptom flare-ups or disease exacerbations. The treatment is given intravenously (into a vein) once a month in a physician’s office. It is the first monoclonal antibody approved for the treatment of MS. In clinical trials, the most frequently reported serious adverse reactions were infections, including pneumonia, temporary hypersensitivity reactions (such as rash, fever, low blood pressure, and chest pain), depression, and gallstones. These serious adverse reactions were uncommon. Common adverse reactions were generally mild and included non-serious infections (such as urinary tract, lower respiratory tract, GI system, and vaginal infections), headache, depression, joint pains, and menstrual disorders.
In October 2000, Novantrone (mitoxantrone) was approved for reducing disability and/or the frequency of clinical relapses in patients with secondary progressive MS, progressive-relapsing MS, or worsening relapsing-remitting MS. It is a potent immune-suppressing agent that acts by suppressing the activity of T-cells, B-cells and macrophages that are thought to lead the attack on the myelin sheath. The drug is given via intravenous (into the vein) infusion, once every three months. Short-term safety and tolerability of Novantrone in MS appear to be manageable. Common side effects include nausea, hair loss, urinary tract infections and menstrual disorders (in females). The longer-term safety of Novantrone in MS, particularly its impact on cardiac (heart) function, may be problematic and limits the use of the drug for two to three years in a lifetime.
Steroids such as methylprednisolone often are prescribed to treat acute attacks of MS, whether the patient is taking an ABC drug or not. These drugs speed the recovery from the acute attack, but do not stop disease progression. After many attacks, steroids may no longer be effective. Long-term use of steroids also has many side effects, including ulcers, weight gain, acne, cataracts, osteoporosis and diabetes.
Chemotherapies that suppress the immune system broadly and were originally designed to treat certain cancers are sometimes used for progressing MS. In addition to Novantrone mentioned above, Cyclophosphamide (Cytoxan) and azathioprine (Imuran) are used similarly, but do not have MS-specific approval from the FDA.
A process in which the antibodies are filtered from a person’s blood called plasmapheresis may be successful in combination with immunosuppressants for short-term treatment of some progressive patients.
For symptom management, health care professionals have an arsenal of medications. For example, baclofen (Lioresal) and tizanidine (Zanaflex) are antispasticity medications often prescribed to relieve muscle spasms, cramping, and tightness of muscles in MS patients. Each has varying side effects in varying degrees; however, your health care professional should be able to find one that provides comfort and relief for almost any symptom you have.
Although currently unapproved by the FDA for MS patients, a growing number of health care providers now consider use of the botulinum toxin Botox as an effective short-term treatment option for certain types of MS-related problems, such as muscle stiffness and urinary problems, when first-line treatment is ineffective.
Non-medical strategies for coping with MS
An MS diagnosis doesn’t have to stop your life, but you will have to learn-and practice-strategies for managing fatigue and dealing with other temporary or long-term disabilities. Physical and occupational therapists can help you develop strategies and select assistive devices to navigate the workplace and home environment.
Physical therapy usually focuses on walking (including using ambulatory aids correctly), balance and stability in standing, maintaining range of motion and functional strengthening. Occupational therapy focuses more on ways to accomplish specific everyday tasks at home and work, as well as managing your energy. Some programs also include techniques to improve memory and concentration. The American Occupational Therapy Association (AOTA) and the American Physical Therapy Association (APTA) provide referrals to specialists and information on MS-related issues as well as other conditions. Visit their Web sites Aota.org and Apta.org for more information.
Check your health plan for coverage. Not all cover physical and occupational therapy.
Symptoms that affect your memory and concentration may be the most painful to talk about. But acknowledging these symptoms and discussing them with healthcare professionals and your family are the first steps towards getting them under control. The National Multiple Sclerosis Society can direct you toward support groups and publications that can help. Visit its Web site.
Things you can do at home to manage fatigue and/or limited mobility include:
De-cluttering your living areas.
Dividing household tasks more equitably with family members.
Simplifying tasks like cooking so they are less stressful-for example, cook more frozen vegetables, or freeze individual servings of a meal, so you can give yourself time off from meal preparation.
Making tasks less fatiguing-for example, put a table and chair in the kitchen so you can sit while cutting or stirring.
Identifying and abiding by your priorities. If it’s important for you to continue working, take some shortcuts with household tasks, or eliminate some of them.
At work you may want to try the following:
Manage your workload to accommodate fatigue. For example, if you feel good in the morning but tire rapidly in the afternoon, do your most demanding work in the morning.
Ask your employer about flex time.
Consider multiple short breaks instead of an hour-long lunch. Perhaps a 30-minute lunch and two 15-minute breaks.
Minimize or combine trips.
Cut back on those leisure activities that are tiring to conserve energy, or make energy-conserving adaptations (such as planting a smaller garden).
When you’re having trouble concentrating, close your office door or take your work to a quiet area, if possible.
“Journaling” can also be a helpful coping strategy. A written or tape-recorded account can help you keep track of when symptoms occur, the management tools that work best for specific symptoms, your medication schedule and many other issues related to your condition. Recording your thoughts and feelings may also be helpful to you.
Exercise can be therapeutic and is at least as important for women with MS as for other women. If you have MS, the last thing you want is to develop other health problems-such as obesity, diabetes or heart disease.
People with MS, however, should not “go for the burn” during exercise because overheating can trigger symptoms and worsen fatigue. Some women with MS enjoy exercising in a cool pool, but others find that the bother of driving and changing twice is too fatiguing. A physical therapist can help you design an appropriate exercise program.
“Multiple Sclerosis: Hope Through Research.” National Institute of Neurological Disorders and Stroke. National Institutes of Health. http://www.ninds.nih.gov. Accessed April 2002.
The National Multiple Sclerosis Society. Copyright 2003. http://www.nationalmssociety.org. Accessed Sept. 2003.
Multiple Sclerosis Society, Inc. Copyright 2000-2003. http://www.msfacts.org. Accessed Sept. 2003.
Van der Mei AF et al. “Past exposure to sun, skin phenotype, and risk of multiple sclerosis: case-control study” British Medical Journal. Vol. 327. Aug. 9, 2003. http://bmj.com. Accessed Sept. 2003.
First Monoclonal Antibody Treatment For Multiple Sclerosis Approved. US Food and Drug Administration. Available at: http://www.fda.gov. Accessed January 3, 2005.
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