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Multiple Sclerosis

Multiple sclerosis (MS) is a potentially disabling disease of the brain and central nervous system.

In MS, the immune system attacks the protective sheath (myelin) that covers nerve fibres which carry signals between your brain and the rest of your body. Eventually, the disease can cause permanent damage or deterioration of the nerves.

MS can occur at any age, but onset usually occurs around 20 and 40 years of age.

The signs and symptoms of MS vary over the course of the disease and depending on the severity of nerve damage and which nerves are affected. Some people with severe MS may lose the ability to walk independently or at all, while others may experience long periods of remission without any new symptoms.

Multiple sclerosis is an autoimmune disease in which the body’s immune system attacks its own tissues, destroying the fatty substance that coats and protects nerve fibres in the brain and spinal cord (myelin), but it is not known why this happens. 

Although the cause of MS is not known, a combination of genetics and environmental risk factors have been identified. 

Risk factors

  • Women are more than two to three times as likely as men are to have relapsing-remitting MS
  • Family history – individuals with parents or siblings have had MS are at higher risk of developing the disease
  • Certain viral infections, such as Epstein-Barr, the virus that causes infectious mononucleosis, have been linked to MS
  • Caucasians, particularly those of Northern European descent, are at highest risk of developing MS. People of Asian, African or Native American descent have the lowest risk.
  • Low levels of vitamin D and low exposure to sunlight is associated with a greater risk of MS
  • Other autoimmune diseases, such as thyroid disease, pernicious anaemia, psoriasis, type 1 diabetes or inflammatory bowel disease, are linked to a slightly higher risk of developing MS 
  • Smokers who experience an initial event of symptoms that may signal MS are more likely than non-smokers to develop a second event that confirms relapsing-remitting MS.
  • There are no specific tests for MS. A diagnosis often relies on ruling out other conditions that might produce similar signs and symptoms. 

    Relapsing-remitting MS often follows a consistent pattern of symptoms, and diagnosis may be confirmed by brain imaging scans, such as MRI.

    Diagnosis can be more difficult in people with unusual symptoms or progressive disease. In these cases, further testing with spinal fluid analysis, evoked potentials and additional imaging may be needed.

    Following a thorough medical history and examination, tests may include:

    • Blood tests – to help rule out other diseases with similar symptoms. Tests to check for specific biomarkers associated with MS are currently under development and may also aid in diagnosing the disease.
    • Spinal tap (lumbar puncture) – can show abnormalities in antibodies that are associated with MS or help rule out infections and other conditions with similar symptoms.
    • MRI scan, sometimes using an injected contrast material – can reveal areas of MS (lesions) on your brain and spinal cord.
    • Evoked potential tests – record the electrical signals produced by your nervous system in response to stimuli and measure how quickly the information travels down your nerve pathways.

As there is currently no cure for multiple sclerosis, treatments focus on helping speed recovery from attacks, slowing the progression of the disease and managing symptoms. Some people have such mild symptoms that no treatment is necessary.

Treatments for MS attacks

  • Corticosteroids may be prescribed to reduce nerve inflammation
  • Plasma exchange (plasmapheresis) removing the liquid portion of part of blood (plasma) which may contain harmful antibodies but retaining the blood cells. The blood cells are then mixed with a protein solution (albumin) and put back into your body. 

Treatments to modify progression

For primary-progressive MS, Ocrelizumab (Ocrevus) may slightly reduce the risk of disease progression.

For relapsing-remitting MS, several disease-modifying therapies are available. These are often most effective if given in the early stages of the disease, when much of the immune response associated with MS occurs.

Many of the disease-modifying therapies used to treat MS carry significant health risks, which must be weighed against potential benefits.

Injectable treatments include:

  • Interferon beta medications can reduce the frequency and severity of relapses. Blood tests to monitor liver enzymes are required due to the possible side effect of liver damage.
  • Glatiramer acetate (Copaxone, Glatopa) may help block the immune system’s attack on myelin.

Oral treatments include:

  • Fingolimod (Gilenya), taken once-daily may reduce relapse rate. Heart rate and blood pressure should be monitored for six hours after the first dose because of risk of a slowed heartbeat. Other side effects include rare serious infections, headaches, high blood pressure and blurred vision.
  • Dimethyl fumarate (Tecfidera), taken twice-daily can help reduce relapses. Side effects may include flushing, diarrhoea, nausea and lowered white blood cell count requiring blood test monitoring on a regular basis.
  • Diroximel fumarate (Vumerity) is similar to dimethyl fumarate but typically causes fewer side effects. 
  • Teriflunomide (Aubagio), taken once-daily can reduce relapse rate. Possible side effects include liver damage and hair loss, and regular blood test monitoring is required. There is a risk of birth defects and therefore conceiving a child should be avoided for both men or women while taking the drug and for up to two-years after. 
  • Siponimod (Mayzent) has been shown by research to reduce relapse rate and help slow progression of MS. It is also approved for secondary-progressive MS. Possible side effects include viral infections, liver problems and low white blood cell count and a risk of harm to a developing foetus during pregnancy.  
  • Cladribine (Mavenclad) is generally prescribed as second line treatment for those with relapsing-remitting MS. It was also approved for secondary-progressive MS. It is given in two treatment courses, spread over a two-week period, over the course of two years. Side effects include upper respiratory infections, headaches, tumours, serious infections and reduced levels of white blood cells. It should not be used by people who have active chronic infections or cancer or women who are pregnant or breast-feeding. Contraception may be advised for both men and women in couples while taking the medication and for six months afterwards.

Intravenous infusion treatments include:

  • Ocrelizumab (Ocrevus) is a humanized monoclonal antibody medication shown by clinical trials to reduce relapse rate and slow worsening of disability. Side effects may include irritation at the injection site, low blood pressure, a fever and nausea. Some people may not be able to take ocrelizumab, including those with a hepatitis B infection. 
  • Natalizumab (Tysabri) blocks the movement of potentially damaging immune cells from your bloodstream to your brain and spinal cord. It may be considered a first line treatment for some people with severe MS or as a second line treatment in others. There is an increased risk of a potentially serious viral infection of the brain called progressive multifocal leukoencephalopathy (PML) in people who are positive for antibodies to the causative agent of PML JC virus. 

Treatments for MS signs and symptoms

  • Physical therapy can help build muscle strength and ease some of the symptoms of MS.
  • Muscle relaxants may help reduce painful or uncontrollable muscle stiffness or spasms
  • Medications also may be prescribed for fatigue, depression, pain, sexual dysfunction, insomnia, and bladder or bowel control problems that are associated with MS.

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