There is as yet no cure for multiple sclerosis (MS). Many individuals living with MS do well with no therapy at all, especially since many medications have serious side effects and some carry significant risks.
Medications:
Corticosteroids: The mainstay of treatment for MS is the use of corticosteroids. Corticosteroids, such as prednisone (Deltasone®) and intravenous (IV) methylprednisolone (SoluMedrol®), are frequently used for visual symptoms of MS and have been shown to prolong the onset of MS if used early in its course. Corticosteroids are also used for acute worsening in those people already diagnosed with MS. Corticosteroids are used in high doses and slowly tapered off over several weeks. Side effects may include: heart failure, high blood pressure (hypertension), high blood sugar levels (hyperglycemia), high or low levels of sodium in the blood (hyper- or hyponatremia), increased risk for infection, low level of potassium in the blood (hypokalemia), personality changes (such as mood swings), stomach ulcer, and swelling (edema) caused by fluid retention.
Immune system modulators: Substances called interferons have also been approved to treat MS. Interferons are normally made by the body, mainly to combat viral infections. Interferons have been shown to decrease the worsening or relapse of MS. Unfortunately, the overall disease progression is not changed, and the side effects of interferons are poorly tolerated. Three forms of beta interferon (Avonex®, Betaseron®, and Rebif®) have now been approved by the U.S. Food and Drug Administration (FDA) for the treatment of relapsing-remitting MS. Beta interferon has been shown to reduce the number of exacerbations and may slow the progression of physical disability. When attacks do occur, they tend to be shorter and less severe. Immune system modulators have been reported to reduce exacerbations and physical disability. Side effects include flu-like symptoms (such as malaise, muscle aches, and fever) and inflammation (including pain, redness, and infection) at the injection site.
Glatiramer acetate (Copaxone®) is a drug that modifies actions of the immune system that may affect the progression of MS. Glatiramer acetate has been shown to decrease the relapse rates of MS by 30% and appears to also have an effect on the overall disabling effects of MS. It is given by subcutaneous injection every day and usually is well tolerated. Glatiramer acetate is better tolerated than the interferons and has fewer side effects. Side effects include chest tightness and palpitations (irregular heart beat).
Natalizumab (Tysabri®) is a monoclonal antibody for the treatment of patients with relapsing forms of MS. Natalizumab was withdrawn from the U.S. market in 2004, but in 2006, the FDA re-approved the limited use of natalizumab in the treatment of MS. The safety and efficacy of natalizumab beyond two years are unknown. Natalizumab has caused a confirmed case and one suspected case of progressive multifocal leukoencephalopathy (PML), a rare and frequently fatal demyelinating disease of the central nervous system.
Other medications: An immunosuppressant treatment normally used in cancer, mitoxantrone (Novantrone®), is approved by the U.S. Food and Drug Administration (FDA) for the treatment of advanced or chronic MS. Side effects of this medication include extreme fatigue, nausea, and vomiting. During clinical trials, this drug was shown to significantly reduce the frequency of attacks in people with relapsing MS. After receiving FDA approval, however, the drug was withdrawn from the market because of reports from three people who developed a rare, often fatal, brain disorder called progressive multifocal leukoencephalopathy. In 2006, after reconsideration of the drug's benefits for people with multiple sclerosis, the FDA agreed to allow the drug to be marketed again under specific conditions. Mitoxantrone is only used for short term (less than three years). Other medications used for MS that suppress immunity include the chemotherapy drugs methorexate (Rheumatrex®), azathioprine (Imuran®), and cyclophosphamide (Cytoxan®).
Muscle weakness, numbness, and stiffness (spasticity) may be treated using medication taken regularly or as needed. These drugs include muscle relaxants, such as tizanidine (Zanaflex®) and baclofen (LIoresal®), benzodiazepines, such as diazepam (Valium®), and anticonvulsants, such as carbamazepine (Tegretol®). Side effects of baclofen and tizanidine include drowsiness, dizziness, and fatigue. Side effects of benzodiazepines include downiness, fatigue, and a potential for addiction. Anticonvulsants may cause drowsiness, fatigue, and headache.
Fatigue may be treated using amantadine hydrochloride (Symmetrel®), pemoline (Cylert®), or modafinil (Provigil®) when frequent napping, adequate sleep at night, and daily exercise do not help. Side effects include nausea, dizziness, and headache. Immune system improvement and alterations in brain chemistry are the likely mechanism of amantadine's action in MS.
Balance and equilibrium abnormalities (such as difficulty walking, uncoordinated movements, tremor) may be treated using medications such as diazepam (Valium®), clonazepam (Klonopin®), propranolol (Inderal®), and mysoline (Primidone®).
Bladder dysfunction, including incontinence (inability to control bladder emptying) and nocturia (frequent urination at night), may be treated using medications such as oxybutynin (Ditropan®), tolterodine (Detrol®), and hyoscyamine (Levsin®). Bladder-emptying regimens, intermittent catheterization, and surgery may also be used. Side effects of medication include headache, dry mouth, constipation, blurred vision, and dizziness.
Constipation may be worsened by inactivity. Treatment includes eating a high-fiber diet, increasing fluid intake, daily exercise, and stool softeners, such as docusate sodium (Colace®). Rectal suppositories or enemas occasionally may be required.
Sexual dysfunction may occur in men and women with MS. Treatments are available for erectile dysfunction and female sexual dysfunction. Vaginal dryness can be improved by using over-the-counter (OTC) lubricants such as KY Jelly®. Male impotence is treated with drugs for erectile dysfunction, including sildenafil (Viagra®) and tadalafil (Cialis®).
Other treatments:
Psychotherapy: Central nervous system abnormalities associated with MS and the psychological and social impact of the disorder often results in mood swings and depression. MS support groups, counseling, and/or antidepressants may be helpful. Tricyclic antidepressants, particularly amitriptyline (Elavil®), are effective for the treatment of nerve pain. Side effects of these antidepressants include dry mouth, constipation, blurred vision, and sedation.
Rehabilitation: Treatment for MS may also include physical therapy, occupational therapy, and speech therapy. Physical therapy uses exercises to help strengthen muscles, reduce pain and spasticity, and improve balance and walking. Assistive devices (such as canes, braces, or walkers) may be used to help individuals remain as independent as possible.
Occupational therapy: Occupational therapy increases independent function in activities of daily living that focus on grooming, dressing, eating, driving, and handwriting. Adaptations in the work and home environment (such as shower chairs, hand rails, or ramps) are based on individual needs.
Speech therapy: Speech therapy may be helpful if slurred speech (dysarthria) or difficulty swallowing (dysphagia) develops.
Caregiver support: Movement disorders confront individuals and their caregivers with many complex problems that must be dealt with for the life of the patient. While it may be emotionally difficult, it is important for patients and caregivers to make informed, carefully considered decisions regarding the future while the patient is capable of making his or her contribution to a planned course of action. Many support groups exist for caregivers of individuals with MS. A doctor or other healthcare professional can help with caregiver support choices.
Plasma exchange (plasmapheresis): Plasma exchange may help restore neurological function in individuals with sudden severe attacks of MS-related disability who do not respond to high doses of steroid treatment. This procedure involves removing some of the blood and mechanically separating the blood cells from the fluid (plasma). The blood cells then are mixed with a replacement solution, typically albumin, or a synthetic fluid with properties like plasma. The solution with the individual's blood is then returned to their body. Replacing plasma may dilute the activity of the destructive factors in the immune system, including antibodies that attack myelin, and help the individual to recover. Plasma exchange has no proven benefit beyond three months from the onset of the neurological symptoms.
Prognosis: Most individuals with MS have a relatively normal life span and life expectancy is about 35 years after onset. After 25 years, approximately two-thirds of patients remain mobile. The disorder eventually results in physical limitations in about 70% of patients.
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