What is the treatment for MS (multiple sclerosis) attacks, progression and RRMS

There is no known cure for MS, however, there are a number of treatment options available to address the various symptoms associated with the disorder. The treatment for multiple sclerosis will depend on the signs and symptoms exhibited by the patient.

The roles of treatment include:

• Treating the specific symptoms exhibited by the affected person
• Treating relapses of multiple sclerosis (this is normally done through steroidal medications)
• Reducing the number of relapses experienced (this is done through disease-modifying therapies)

The patient will be supported by a team of medical professionals and specialists who will work together to ensure that the best possible forms of treatment are being implemented.

What kind of health-care specialist will treat MS (multiple sclerosis)?

There are a number of different specialists that are involved in the team of medical professionals that will treat a patient with MS. Some of these professionals consist of the following:

• Primary health care provider – This care provider will be either one’s family doctor or someone working with them to help in keeping the patient as healthy as possible. This is done by tracking their glucose levels, cholesterol, blood pressure, immunisation status and a number of other general medical and health-related factors on an ongoing basis to ensure good health.  GP’s will generally refer patients they suspect may have MS to a neurologist for specialist evaluation and diagnosis as well as work together with them in ongoing care.
• Neurologist – This is a kind of doctor who specialises in diseases of the nervous system and brain. There are also some of these specialists who have received additional specialised training in regard to the treatment of MS.
• Radiologist – This is a specialist who works closely with the referring neurologist and reads the visuals produced by imaging studies (MRI’s), comparing the results that are obtained over time in order to monitor the patient’s MS status and determine whether the disease has stabilised or is progressing.
• Speech pathologist – These specialists work with MS patients who experience symptoms affecting their speech. Specific therapeutic techniques are employed to assist the patient in improving the clarity of their speech. A speech pathologist is also able to work with the patient to help them perform cognitive exercises to aid in the improvement of memory related issues. If there are any issues with swallowing present, the speech pathologist can help in determining what the cause of these are and whether further therapy is necessary to improve the swallowing ability of the affected individual.
• Physical therapist (PT) – A physical therapist is likely to work with MS patients suffering from mobility issues, helping them to regain some form of their strength and/or mobility and determine how this can be maintained going forward.
• Occupational therapist (OT) – An occupational therapist will work closely with a PT (physical therapist) in order to help with any mobility issues and provide any additional assistance the patient may need in making modifications to their home and surroundings through implementing various actions or tools and teaching them how to use these in order for their daily activities to be safely performed.
• Clinical psychologist – The patient may need the help of a clinical psychologist to assist in coming to terms and coping with multiple sclerosis when first diagnosed. These professionals can also be helpful to those suffering from anxiety or depression as a result. In some cases, a psychologist will work together with a psychiatrist who will determine whether or not medications are needed and prescribe any that are required for the benefit of the patient, for example, a number of MS patients are on anti-depressants.

What are the treatments for MS attacks?

• Corticosteroids – These include medications such as intravenous methylprednisolone and oral prednisone. These medications aid in reducing nerve inflammation. Some of the possible side effects include high blood pressure, fluid retention, mood swings and insomnia.
• Plasmapheresis (plasma exchange) – This process involves a portion of the patient’s blood plasma being removed and then separated from the blood cells. Thereafter, the blood cells are combined with a special protein solution known as albumin and be put back into the patient’s body. A plasma exchange is often the first line of treatment if the symptoms of MS are new and severe and the patient has not responded to any steroidal medications (corticosteroids).

Treatments to modify the progression of MS

Medications and therapies that assist in reducing the number of relapses experienced and their severity are known as disease-modifying therapies. These types of therapies attempt to reduce the severity of the scarring and damage done to the myelin sheaths (protective covering of the nerve cells). These types of treatments also aim to slow down the progression of various disabilities associated with MS (both cognitive and physical). However, there is little research on the long-term benefits of many of these types of medications as yet.

Treatments that modify the course of the disease are also not always suitable for all individuals suffering from MS.

For patients suffering from PPMS (primary-progressive multiple sclerosis), doctors will normally prescribe ocrelizumab (Ocrevus) as this drug is the only Food and Drug Administration (FDA) approved therapy to aid in modifying diseases and that slows down the progression of this form of MS.

For those with RRMS (relapsing-remitting multiple sclerosis), there are a number of disease-modifying treatments and therapies available.

The majority of immune system responses to MS occur during the initial stages of the condition. Aggressively treating the symptom associated with this immune response during the first phase of the condition may slow the damage incurred and the rate at which new lesions are formed as well as increase the rate at which the patient replaces damaged myelin.

Most disease-modifying therapies that are used for the treatment of MS come with a number of side effects and health risks. The right form of treatment will be selected through careful consideration and assessment by the team of medical professionals involved and will be based on several factors such as the severity and duration of the condition, existing health issues, the effectiveness of any previous MS medications, their affordability etc.

Patients who do not suffer from relapses are highly unlikely to benefit from these kinds of treatments and are also at risk of experiencing the various side effects of these medications unnecessarily.

The treatment options for RRMS include the following:  

Beta interferon

The types of this drug that are often used include:

• Beta 1a (Rebif, Plegridy and Avonex)
• Beta 1b (Extavia and Betaferon)

These medications are all administered through an injection either under the patient’s skin or into muscle and are able to reduce the severity and frequency of relapses experienced.

Beta interferons have some side effects which include flu-like symptoms (usually experienced for 24 to 48 hours post injection) and may cause a reaction at the site of the injections.

The patient will also need to have regular blood tests conducted in order for liver enzymes to be monitored due to liver damage being a possible side effect of these drugs.

Glatiramer acetate

A commonly known brand of glatiramer acetate is known as Copaxone. This medication is injected under the patient’s skin and is administered every day or, when in higher doses, three times a week.

Glatiramer acetate prevents the immune system from attacking the myelin sheath.

An MS patient will be offered this kind of drug if they suffer from RRMS (relapsing-remitting multiple sclerosis), have suffered from a relapse recently, and/or had MRI scans that show the MS to be active.

Some of the common side effects of glatiramer acetate include issues with hardening or redness of the patient’s skin at the sites of injection, as well as the patient suffering from occasional flushing or palpitations after administration. 

Teriflunomide

This drug is administered in the form of a tablet that the patient will need to take once a day. Teriflunomide is commonly branded and known as Aubagio.

The common side effects of this drug have been known to include hair loss or hair thinning, headaches, nausea and diarrhoea. The patient will also need to have frequent blood tests during the first few months of treatment in order for their doctor to monitor and detect any medication induced issues with liver function.

This drug is harmful to a developing foetus and therefore should not be given to pregnant women and the use of contraception by both males and females is recommended while taking it and for up to 2 years post-use.

Natalizumab

This drug, commonly branded and known as Tysabri, is injected into the patient’s vein, this is referred to as an infusion, once a month (every 28 days).

Natalizumab was created to block any immune cells that could be potentially damaging to the nerve cells, effectively preventing them from moving from the bloodstream to the spinal cord and brain. This drug is often considered as the first line of treatment for certain patients suffering from severe multiple sclerosis

A patient is likely to be prescribed this medication if they are suffering from severe RRMS that is progressing at a rapid rate. For example, the patient has had more than two severe MS relapses in the past year and magnetic resonance imaging (MRI) scans have detected that the disease is progressing.

The side effects of Tysabri or natalizumab may include joint pain, dizziness, hives, headaches and nausea during the time of infusions.

The biggest concern regarding this treatment is that the patient has a risk of PML (progressive multifocal leukoencephalopathy), this is a rare and often fatal condition in which the brain becomes infected. This side effect is uncommon when using natalizumab, however, it may be a severe issue in regard to the long-term use of natalizumab.

Fingolimod

This drug is often referred to by its brand name of Gilenya and is taken daily in tablet or capsule form.

Fingolimod helps to reduce the number of MS relapses experienced. However, the patient will need to have their heart rate monitored for the first six hours after the initial dose of treatment has been administered as this drug may slow heart rate.

The patient is likely to be offered Gilenya if they are suffering from RRMS (relapsing-remitting multiple sclerosis) and have experienced a steady or increasing number of relapses with no improvement experienced when using other medications (e.g. beta interferons).

This type of medication does not normally result in any significant or severe side effects, however, some patients may experience an increased risk of infection or suffer from diarrhoea, visual problems, headaches or liver issues. 

Alemtuzumab

Often branded as Genzyme or Lemtrada, alemtuzumab will initially be given to a patient intravenously for a period of five days. This will then be followed by another course of the treatment a year later, over a three-day period.

Alemtuzumab aids in reducing any relapses associated with MS through targeting a specific protein found on the surface of the patient’s immune cells and depleting the patient's white blood cell count. This action helps to limit any potentially harmful nerve cell damage that is caused by the individual’s white blood cells, however, the effect can also increase the risk of other autoimmune disorders and infections.

Patients will be given alemtuzumab if they suffer from RRMS and have experienced a relapse in the last year and have had MRI scans which show MS to be active.

The commonly seen side effects of Genzyme or Lemtrada often include headaches, an increased risk of infection, fever and rashes. Regular urine and blood tests will need to be conducted in order for the treatment and its effects to be monitored.

Dimethyl fumarate

Commonly branded and known as Tecfidera, this drug is taken orally in tablet form twice daily.

As with the previously mentioned drugs, the patient will have this drug prescribed to them should they be suffering from RRMS and/or have MRI scans showing MS to be active. This drug helps to reduce relapses.

Commonly side effects include headaches, nausea, diarrhoea, abdominal pain and hot flushes. Any stomach issues experienced will usually subside after a period of a month. Hot flushes do tend to continue throughout the treatment but these are not generally a major concern or issue for patients. 

Mitoxantrone

This drug is an immunosuppressant, meaning that it suppresses the patient’s immune system response in an attempt to stop the damage done by the immune system to the myelin sheaths.

However, mitoxantrone may be harmful to the patient’s heart and is also associated with the development of certain cancers of the blood. Because of this, the use of this drug for the treatment of MS is not always recommended and is normally only prescribed for the treatment of severe, advanced MS.