Brunilda Nazario, MD
Living with multiple sclerosis means living with uncertainty. The course of the disease is very difficult for doctors to predict. Some people live with MS for years without suffering serious symptoms. Others may rapidly become disabled. Why the course of the disease varies so widely remains unclear. One thing is certain. Most people with MS experience periodic relapses, also called flare-ups or attacks. These can be mild or severe. They may show up in many different ways. Symptoms can include:
“Between 85% and 95% of MS patients begin with what we call remitting/relapsing MS,” says Anne Cross, MD, professor of neurology at Washington University School of Medicine. During that phase of the disease, the pattern of relapses varies widely among patients. Some people have frequent relapses. Others have very few. The average is typically one to two attacks a year, according to Cross.
Doctors can help MS patients live as active and normal a life as possible by treating acute relapses as soon as they occur. Yet there are instances when doctors may recommend not treating a relapse.
Doctors follow two basic strategies in treating multiple sclerosis. To slow the long-term progression of the disease and reduce the frequency of flares, doctors prescribe “disease-modifying” agents. The most commonly used drugs are interferon (Avonex and Rebif ), fingolimod (Gilenya), mitoxantrone (Novantrone), and natalizumab (Tysabri). Other MS drugs used to reduce the number of flares or disease exacerbation include interferon beta (Betaseron and Extavia) or drugs such as Copaxone (glatiramer acetate).
Research shows that these disease-modifying drugs can decrease the rate of relapses by about 30%. They also lessen the severity of relapses. Not all forms of MS respond to these drugs, however. And even when the drugs work, they do not offer a cure. Most people continue to experience periodic relapses.
When acute attacks occur, doctors can suppress the underlying autoimmune damage, which is at the heart of MS, with the use of corticosteroids. Studies have shown that corticosteroid treatments significantly reduce the severity and shorten the duration of relapses for most patients. A typical dose is between 500 and 1,000 milligrams of intravenous methylprednisolone, which is gradually reduced over several weeks.
“But there is no clear-cut best way to administer corticosteroids, so doctors usually go on the basis of their own clinical experience with the disease,” says Ben W. Thrower, MD, medical director of the Andrew C. Carlos Multiple Sclerosis Institute at the Shepherd Center in Atlanta.
Even when they are untreated, however, acute relapses of MS typically resolve on their own over a matter of days or weeks. For that reason, and because corticosteroids are powerful drugs with some unwanted side effects, doctors may recommend using them only for relapses that significantly affect a patient’s function. Adverse side effects of corticosteroids can include fluid retention, weight gain, elevated blood pressure, and mood swings.
“If a patient comes in with a little bit of numbness in one foot, I may recommend just waiting it out,” Thrower tells WebMD. “But if a patient comes in with significant problems walking, for example, I’ll recommend corticosteroids.”
One of the most common forms that MS relapses take is optic neuritis, cause by temporary inflammation of the optic nerve. Symptoms include blurred vision and eye pain. Like so many other features of the disease, the severity of optic neuritis varies widely among patients. “If a patient has only mild vision problems, we may decide to watch and wait without treating the relapse,” says Cross. “But if vision is significantly affected or there’s pain, then we’ll usually recommend treatment.”
In addition to immune-suppressing corticosteroids, which suppress the underlying disease process in MS, a variety of drugs can be used to treat specific symptoms of relapses. These include antidepressants to treat depression, erectile dysfunction drugs to ease sexual problems associated with MS, and a new drug called dalfampridine (Ampyra), which has been shown to help improve walking in some patients.
Can treating relapses quickly and aggressively reduce nerve damage and slow the long-term progression of the disease? Doctors don’t have a complete answer yet. In theory, it makes sense that if you limit damage from inflammation, the disease will progress more slowly. Some researchers have even tried using periodic treatments with corticosteroids in hopes of delaying the progression of MS. But so far, there’s little evidence that the approach offers any benefit.
“In general, I believe that steroids hasten recovery and may reduce the risk of future relapses for a time,” neurologist Elliot Frohman, MD, an MS researcher at the University of Texas Southwestern Medical Center, wrote in an email to WebMD.
But one recent study, called the Optic Neuritis Treatment Trial, found that treating relapses may have little if any effect on the long-term course of MS. Researchers looked at acute relapses that caused optic neuritis. Some patients were given oral prednisone. Others received no treatment at all. Patients in the high-dose prednisone group recovered more quickly from optic neuritis. But a year later, researchers found no difference between the treated and untreated groups in terms of disease progression.
SOURCES:Anne Cross, MD, professor of neurology, Washington University School of Medicine.Ben Thrower, MD, medical director, Andrew C. Carlos Multiple Sclerosis Institute, Shepherd Center, Atlanta.Milligan, N. Journal of Neurology, Neurosurgery, and Psychiatry, 1987; vol 50: pp 511-516.National Institute of Neurological Disorders and Stroke: “NINDS Multiple Sclerosis Information Page.”Tremlett, H. Neurology, November 2009; vol 73: pp 116-122.Shams, P. International MS Journal, September 2009; vol 16: pp 82-89.National Multiple Sclerosis Society: “Disease Management Consensus Statement.”
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