Multiple sclerosis

Diagnosis

Diagnosing multiple sclerosis (MS) can be challenging due to the presence of similar neurological symptoms in various other illnesses. Accurate diagnosis often involves the process of differential diagnosis, where other conditions with similar signs and symptoms are ruled out. It’s important to note that there is currently no single definitive test available to provide a conclusive diagnosis of MS.

• Physical examination: A physical exam will be performed to determine what is causing the symptoms. The healthcare provider may also inquire about one’s medical history. Several tests may be advised.
• Blood tests: Certain biomarkers linked to MS are currently being developed and may aid in the diagnosis of the disease. Blood tests are often performed to rule out other diseases with similar symptoms.
• MRI: Lesions form when the myelin sheath that surrounds the nerves is damaged. An intravenous injection of a contrast substance may be given to highlight lesions that will show that the condition is active. Lesions in the brain or spinal cord seen during MRI scans could indicate multiple sclerosis.
• Spinal tap or lumbar puncture: A spinal tap can be used to rule out infections and other conditions that have symptoms similar to MS. This sample can detect abnormalities in antibodies linked to MS. A novel antibody test targeting kappa free light chains might offer swifter and more cost-effective results compared to previous spinal fluid tests for multiple sclerosis.
• Evoked potential tests: The tests examine electrical activity in specific parts of the brain and spinal cord in response to stimuli.

People with atypical symptoms or progressive disease may have a more difficult time being diagnosed with MS. Additional testing, such as spinal fluid analyses, evoked potentials, and imaging, may be required.

Treatment

There is currently no known cure for multiple sclerosis (MS). However, a comprehensive treatment plan aims to manage symptoms, prevent relapses, and slow down the progression of the disease. Such a plan may include:

Treatments for MS attacks

• Corticosteroids: Those with severe attacks may be prescribed with a large dose of corticosteroids, such as oral prednisone and intravenous methylprednisolone. The medicine reduces nerve inflammation. They slow the deterioration of the myelin sheath that surrounds the nerve cells.
• Plasmapheresis or plasma exchange: If the symptoms are new, severe, and have not responded to steroids, plasma exchange may be performed. The procedure requires the blood cells to be separated from the liquid portion of the blood or plasma. After that, the blood cells are combined with a protein solution, known as albumin, and is returned to the body.

Treatments to modify progression

• Disease-modifying therapies (DMTs): The FDA has approved several drugs for long-term MS treatment. These medications aid in the reduction of relapses, also known as flare-ups or attacks. They slow the progression of the disease. They can also prevent new lesions on the brain and spinal cord from occurring.

During the early stages of multiple sclerosis (MS), the immune response is most active. To effectively manage the condition, early and aggressive therapy with various disease-modifying therapies (DMTs) is recommended. These treatments are available for relapsing-remitting MS, with some offering potential benefits for secondary progressive MS, and one specific treatment showing efficacy for primary progressive MS. However, when determining the most suitable therapy, several factors must be taken into account due to the potential serious health risks associated with these treatments. Factors such as the duration and severity of the disease, previous effectiveness of MS treatments, presence of other health conditions, cost considerations, and plans for pregnancy should all be considered in the decision-making process.

Injectable, oral, and infusion medicines are among the treatment options for relapsing-remitting MS.

• Common injectables include:
  • Interferon beta medications: These medications are injected beneath the skin or into the muscle. The frequency and severity of relapses have been shown to lessen when taking these drugs. Interferon beta medications function by interfering with diseases that attack the body and may reduce inflammation and enhance nerve growth.
  • Glatiramer acetate: This medication works by stopping the immune system’s attack on myelin. This is often administered through skin injections.
  • Monoclonal antibodies: This medication is administered via skin injection and can reduce brain lesions and alleviate the progression of symptoms associated with multiple sclerosis. Ofatumumab attacks B cells that cause nerve injury.
• Oral treatments include:
  • Teriflunomide: This medication focuses on minimizing relapse rates. Regular blood test monitoring is necessary when taking this medication. This is often administered orally, usually once a day. Teriflunomide can harm the liver, cause hair loss and has been linked to birth abnormalities. Pregnancy is not recommended while taking this drug and for up to 2 years.
  • Dimethyl fumarate: Monitoring one’s blood test is necessary when taking this medication. Reduced relapse rates have been proven with taking this drug twice a day. Flushing, diarrhea, nausea, and a decrease in white blood cell count are all possible side effects.

Diroximel fumarate, a known derivative of dimethyl, is also approved for treatment of MS but with less negative side effects.

• • Monomethyl fumarate: This medication provides a gradual and consistent effect through its delayed release properties. The intention behind its timed release is to reduce potential side effects.
  • Fingolimod: This oral medication, taken once a day, decreases the frequency of relapses. Six hours after the initial dose, heart rate and blood pressure should be checked due to a possibility of temporary slowdown of heart rate.
  • Siponimod: Studies indicate that this oral medication, taken once a day, has demonstrated the ability to lower relapse rates and delay the advancement of MS, and can be used to manage secondary-progressive MS. Some people may need to have their heart rate and blood pressure monitored for six hours following the first dosage. Regular blood test monitoring is required when taking this drug.
  • Ozanimod: This once-daily oral medicine reduces the relapse rate of multiple sclerosis.
  • Ponesimod: This medicine exhibits a lower relapse rate. Compared to other medications employed in the treatment of multiple sclerosis, it has been shown to result in fewer brain lesions. The recommended dosage for this oral medication is once a day, following a gradually increasing schedule.
  • Cladribine: This medication is administered in two two-week treatment cycles over the course of two years. Blood tests should be monitored while on this drug. People with active chronic illnesses or malignancies, as well as pregnant or breastfeeding women, should not take this medication. This medicine is typically provided as a second-line treatment for patients with relapsing-remitting MS, but it has also been approved for secondary-progressive MS.
• Infusion treatments include:
  • Natalizumab: This medication may be considered as an initial treatment for individuals with severe multiple sclerosis or as a secondary treatment for others. Its goal is to hinder the movement of immune cells that could potentially cause damage from entering the brain and spinal cord through the bloodstream.

This monoclonal antibody has demonstrated effectiveness in reducing relapse rates and slowing down the progression of disability. However, it raises the risk progressive multifocal leukoencephalopathy (PML) in persons who have antibodies to the PML JC virus. PML is a potentially fatal viral infection of the brain.

• • Ocrelizumab: This humanized monoclonal antibody drug is the first DMT for use in both relapse-remitting and primary-progressive MS. In relapsing-remitting multiple sclerosis, this treatment lowers the relapse rate and the risk of debilitating progression. It also inhibits the progression of multiple sclerosis’s primary-progressive form. Ocrelizumab is administered through intravenous infusion.

However, ocrelizumab may raise the risk of infections and certain cancers, including breast cancer. This medication is not recommended for patients with hepatitis B.

• • Alemtuzumab: This medication is typically prescribed for patients with aggressive MS or as a second-line treatment if another MS medicine has failed. The treatment consists of five consecutive days of medication infusions, followed by another three days of infusions a year later.

Alemtuzumab, a monoclonal antibody, works by targeting a protein on the surface of immune cells and reducing white blood cells, which minimizes MS relapses and shows MRI advantages. This helps reduce possible nerve injury produced by white blood cells.

However, risks of thyroid autoimmune diseases, rare immune-mediated kidney disease, other infections, and autoimmune illnesses significantly increase with this medication.

Researchers are discovering more about how current disease-modifying medicines function to prevent relapses and lesions in the brain caused by multiple sclerosis. More research will be conducted to evaluate whether treatment can delay the disease’s impairment.

Latest research and emerging treatments include:

• Bruton’s tyrosine kinase (BTK) inhibitor: The primary mechanism involved in this medication is regulating the immune cells known as B cells, present in the central nervous system. Treatment with BTK inhibitor is currently under research for its potential in treating relapsing-remitting multiple sclerosis and secondary-progressive multiple sclerosis.
• Stem cell transplantation: The effectiveness of this approach in reducing inflammation and potentially restoring immune system equilibrium in individuals with multiple sclerosis is still under investigation. In this procedure, stem cell transplantation kills a person’s immune system and then replaces it with transplanted healthy stem cells.

Ocrelizumab is the sole disease-modifying therapy (DMT) approved by the FDA for treatment of primary-progressive MS. Individuals who undergo ocrelizumab treatment exhibit a slightly lower likelihood of disease progression compared to those who receive no treatment.

FDA-approved disease-modifying medicines such ozanimod, siponimod, and cladribine can potentially decelerate the progression of disabilities in secondary-progressive MS.

Treatments for MS signs and symptoms:

• Physical rehabilitation: Multiple sclerosis can have an impact on physical function. Maintaining mobility will be easier if patients stay physically healthy and strong. Physical therapy, in conjunction with the use of a mobility device as needed, can also assist control leg weakness and other gait issues that are frequently associated with MS.

Exercises for stretching and strengthening as well as utilization of assistive devices to enhance the ease of accomplishing everyday activities are beneficial with the supervision and guidance of a physical or occupational therapist.

• Muscle relaxants: Baclofen, tizanidine, and cyclobenzaprine are muscle relaxants for painful or involuntary muscle stiffness or spasms, especially in the legs. Onabotulinumtoxin A treatment is an option for patients suffering with spasticity.
• Medications to reduce fatigue: Antidepressant medications, such as selective serotonin reuptake inhibitors, may be prescribed to alleviate MS-related fatigue. Although amantadine, modafinil, or methylphenidate is still among the options, recent trials found that they were no better than a placebo at improving MS-related fatigue and caused more frequent side effects.
• Medication to speed up walking: Medication to assist in improving walking speed may be prescribed. Drugs like dalfampridine is not recommended to anyone who has a history of seizures or kidney failure. Urinary tract infections, vertigo, sleeplessness, and migraines are all possible adverse effects.
• Other medications: Discomfort, sexual dysfunction, sleeplessness, and bladder or bowel control issues associated with MS may also be treated with medication.