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Multiple Sclerosis

 


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Condition
Multiple sclerosis
Class
Central nervous system
Description
Multiple sclerosis (MS) is the most common disabling disease of the central nervous system (the brain and spinal cord) to affect young adults, with an estimated 100,000 people in the UK diagnosed with the disease. The disease usually first appears between 20 and 40 years of age, with women being more commonly affected than men.

Multiple sclerosis is a chronic inflammatory disease affecting the nerve fibres of the brain and spinal cord. Nerve fibres are surrounded by a fatty sheath called myelin, which protects the nerves and allows impulses or signals to be passed down the nerve fibre. In multiple sclerosis, the myelin sheath is damaged so interfering with the passage of nerve signals that may be responsible for sight, movement, thought, balance, speech and emotions. The name ‘multiple sclerosis’ refers to the multiple scars (or scleroses) on the damaged myelin sheaths.

Multiple sclerosis is a complex and unpredictable condition, which varies from person to person and does not follow a set pattern. The symptoms experienced will depend on the position and extent of the scarring within the central nervous system and on how much damage has occurred. Symptoms can come and go from day to day but there can also be relapses followed by periods of complete or partial remission.

A relapse is a significant worsening or a return of symptoms lasting for anything from a few days to a few months. Relapses are also referred to as exacerbations, episodes and attacks. A remission is a period of recovery, when symptoms become less severe or disappear altogether.

Multiple sclerosis is often divided into different types. It is not usually possible to determine which type of multiple sclerosis is present when the disease is first diagnosed – this will only become apparent over time. Some early symptoms, particularly those affecting sight and sensation, suggest a more positive long-term outlook or prognosis. However, it is impossible to say with any certainty how the multiple sclerosis will develop. It is important to remember that whatever the type of multiple sclerosis, the effect on lifespan is usually minimal.

There are four different types of multiple sclerosis, characterised according to the course the disease takes:

Relapsing-remitting multiple sclerosis
An estimated 85 to 90% of patients affected by multiple sclerosis initially have this form of the disease. They experience unpredictable attacks or relapses on average once or twice per year, with good or complete remission in between. However, there is a tendency for symptoms to worsen gradually over time. 15-20% of people will have a type of relapsing-remitting multiple sclerosis characterised by only very occasional relapses with good recovery in between and few or no persistent symptoms. This is sometimes referred to as benign multiple sclerosis.

Secondary progressive multiple sclerosis
This type of multiple sclerosis is characterised by periods of progressive decline in nerve activity following the acute attacks without periods of remission. It is the most common form of multiple sclerosis and develops in about 80% of people who originally had relapsing-remitting multiple sclerosis.

Primary progressive multiple sclerosis
This form of the disease occurs in about 10% of people who never have remission after their initial symptoms. There is a gradual and continuous deterioration over a period of years without remission and usually with no relapses. Primary progressive multiple sclerosis tends to affect people who are older when the disease first appeared.

Progressive relapsing multiple sclerosis
Patients with this type of multiple sclerosis have a steady decline in the nerve activity from the outset, but also suffer superimposed attacks. It is the least common of all the different types of multiple sclerosis.
Causes
The exact cause of multiple sclerosis is not yet fully understood but is thought to be a combination of environmental and genetic factors that trigger an autoimmune response. An autoimmune response is one in which the body’s immune system starts to attack the body’s own tissue as if it were an invading bacterium or virus.

During the autoimmune response, special cells of the immune system, called T-lymphocytes are believed to cause leaks in the blood brain barrier, a layer that normally protects the brain and spinal cord. These leaks allow the T-lymphocytes to enter the central nervous system and attack the myelin sheath, mistaking it for an invading virus. A deficiency of uric acid, which normally helps protect the blood brain barrier, may be involved in the process.

In the early stages of multiple sclerosis, the body tries to repair the damaged myelin sheath by a process called remyelination. This may explain why people experience a remittance in symptoms. However, the body cannot manage to continue repairing the sheath and so symptoms progressively get worse.
Symptoms
Multiple sclerosis can cause a wide variety of symptoms, but most people with the condition only experience a small number of these and no two people with multiple sclerosis experience the same symptoms to the same degree. Symptoms can come and go. They can occur at any time and may last for hours, days, weeks or months.

Symptoms depend upon the nerves affected and the extent to which the conduction of impulses in the nerves is affected.

Some of the most common symptoms include:

Visual disturbances - Eye problems can include temporary loss of vision, double vision, pain and reduction in colour vision. Optic neuritis, or inflammation of the optic nerve, is often the first symptom of multiple sclerosis for many people.

Fatigue - An overwhelming sense of exhaustion and weariness is a common symptom of multiple sclerosis. It can be particularly difficult to cope with since it will not be obvious to other people.

Muscle spasm - Nerve damage can cause muscles to contract into tight, often painful spasm or remain stiff and unresponsive, making balance, walking, speech and swallowing difficult.

Pain - Pain may be caused either by damage to the nerves (neuropathic pain), associated with stabbing pains, extreme skin sensitivity and burning sensations, or by damage to the tendons, ligaments, muscles and bones (musculoskeletal pain). This second type of pain is not caused directly by multiple sclerosis but can develop through altered posture and positioning.

Bladder and bowel problems - Bladder problems include needing to go to the toilet more often (frequency), a feeling of needing to go immediately (urgency) and incomplete emptying of the bladder. The most common bowel problem is constipation, although problems controlling bowel movements can also occur.

Cognitive and emotional problems - include short-term memory loss, inability to concentrate, poor judgement and reasoning, mood swings.
Treatment
Management of multiple sclerosis is divided into two main types, symptomatic treatments and disease modifying treatments. Symptomatic treatments help ease the symptoms of multiple sclerosis. Disease modifying treatments help reduce the frequency and severity of relapses.

Symptomatic treatments
The treatment of symptoms is aimed at the management of spasticity, pain, fatigue and bladder dysfunction.

Anti-spasiticity drugs help to relieve the muscle spasm that can be causing pain and making movement and posture difficult. Baclofen, dantrolene, diazepam, tizanidine are the usual drugs given for spasticity. An extract of cannabis has also been shown to help relieve muscle pain and spasm. A legally licensed form of cannabis extract is available as an oral spray, called Sativex. It is used to improve symptoms in patients with moderate to severe spasticity who have not responded adequately to other anti-spasticity agents.

Fampridine is a drug that blocks potassium channels in nerve fibres thereby improving the transmission of impulses down damaged nerve fibres. It helps reduce spasticity and so helps walking speed and ability. Fampridine is approved in America (as Ampyra), but its licence application was turned down in Europe.

Other drugs for pain relief include gabapentin, and some antidepressants and anticonvulsants. These drugs will also help relieve the symptoms of pins and needles and other painful sensations.

Bladder problems are managed with drugs such as oxybutynin, propiverine and tolterodine for incontinence, or with drugs such as distigmine for urinary retention.

Amantadine has been used to help overcome the feelings of fatigue.

Disease modifying drugs
The corticosteroid, methylprednisolone, is used for its anti-inflammatory and immune modifying actions to reduce the duration of relapses and accelerate recovery. Methylprednisolone is given in high doses by intravenous injection then orally.

The two main drugs used for the prevention of relapses are interferon beta and glatiramer. Interferon beta is used for relapsing-remitting multiple sclerosis and in secondary progressive multiple sclerosis. It reduces exacerbations partly by inhibiting interferon gamma which appears to act as a disease activator. Patients treated with recombinant interferon beta have obtained a reduction in the rate and severity of exacerbations. The reduction in disease activity has also been proven by the use of MRI (magnetic resonance imaging), a diagnostic technique used in multiple sclerosis. Glatiramer has also been shown to reduce the number of relapses and improve disability. It works in a different way to interferon beta and so there may be additional benefit if the two types of drug are given together.

Natalizumab is a monoclonal antibody used for the treatment of relapsing remitting multiple sclerosis in people who have had two or more disabling relapses in a year and have signs of new multiple sclerosis inflammation on a recent MRI scan. Natalizumab is associated with a risk of a potentially fatal condition called PML (progressive multifocal leukoencephalopathy). PML is caused by a viral infection in the brain. The risk of PML increases after 2 years of therapy and so people taking natalizumab require close monitoring to detect early signs of the disease.

There are a number of other disease modifying drugs. These include a drug called fingolimod (Gilenya), recently licensed in Europe for people with rapidly evolving severe relapsing remitting multiple sclerosis, and for second line treatment of people whose disease remains active despite treatment with interferon beta or glatiramer. It is also undergoing trials as a potential treatment for primary progressive multiple sclerosis. Fingolimod acts by trapping T-cells and preventing them from entering the CNS and causing damage to the myelin sheath.

Unfortunately, the application for a licence for another drug called cladribine was withdrawn following reports of cancer in people taking part in the clinical trials, but there is hope that another licence application will be made in the future.
When to consult your pharmacist
If you are being treated for multiple sclerosis and there are things that you do not understand about your medicines, your pharmacist will be able to explain to you what the medicines are for and how they should be used. If you want to try some of the dietary changes, your pharmacist will be able to supply many of the supplements that are recommended for the management of multiple sclerosis.
When to consult your doctor
As the symptoms of multiple sclerosis differ widely and can come and go, diagnosis of the disease is often difficult. Initially, your doctor will examine you, take a detailed medical history and will ask you to keep a record of your symptoms.

If your doctor suspects multiple sclerosis, you will be sent to hospital for further tests such as an MRI scan which is able to detect scarring on the myelin sheaths. The results of the MRI scan may be supported by other tests such as a lumbar puncture to examine the fluid in your spinal cord for tell-tale signs of inflammation, and VEPs (visual evoked potentials) that can measure the speed at which nerves conduct impulses.

If multiple sclerosis is diagnosed, treatment is best handled by a multi-disciplinary team of specialist health professionals as there is such a wide range of possible symptoms. The team may include, for example, a doctor, nurse, physiotherapist and occupational therapist.
Living with multiple sclerosis
Although a diagnosis of multiple sclerosis can be devastating to you and other members of your family, it will help if you have a positive attitude to the disease and try to keep as fit and as healthy as you can.

Try to exercise, as exercise is important in maintaining general well-being. Although your symptoms may make some activities difficult, there are organisations that run classes and exercises specifically for patients with multiple sclerosis (see MS Trust’s website for details).

Be selective in what you eat. There is some evidence to show that adopting a healthy, well balanced diet will help improve the symptoms of multiple sclerosis as well as reducing the risk of other conditions such as heart disease, stroke and cancer. Linoleic acid, found in sunflower, corn, soy and safflower oils may help slow the disabling effects of multiple sclerosis. Benefits have been shown in some people taking 17g to 23g of linoleic acid per day, usually in the form of a spread on bread or toast.

You may also find that complementary medicines may help. Reflexology, massage, exercise, and magnetic field therapy may be helpful in terms of general well being.

If you do decide to try dietary supplements or complementary therapies you should be aware of the costs involved as these therapies are not generally available on the NHS, nor too have the risks or benefits of these treatments been fully evaluated. Always tell your doctor or specialist if you are using these therapies just in case they may interfere with your prescribed treatments.

Try to live as full a life as you can. Join a support group, not only will it give you and interest and help you meet new friends, you will learn from the experiences of others who have been similarly affected by multiple sclerosis.

If you need help with transport, housing or in managing your finances, insurance and legal affairs get in touch with the MS Trust or the MS Society, both have excellent helplines and on-line information services.
Information
Multiple Sclerosis Society
The Multiple Sclerosis Society is the UK's largest charity for people affected by multiple sclerosis. The Society funds research, runs respite care centres, provides financial assistance, education and training and produces numerous publications that describe multiple sclerosis and its treatment.

Helpline: 0808 800 8000
helpline@mssociety.org.uk
www.mssociety.org.uk

Multiple Sclerosis Trust
The Multiple Sclerosis Trust is a UK charity, providing information for anyone affected by multiple sclerosis, running education programmes for health professionals, funding for practical research and campaigning for specialist multiple sclerosis services. The Trust’s vision is to enable people with multiple sclerosis to live their lives to the full.

Free Phone Information Service: 0800 032 38 39
Email: info@mstrust.org.uk
www.mstrust.org.uk

NICE guidance
Information for people with multiple sclerosis, their families and carers and the public
http://www.nice.org.uk/nicemedia/live/10930/29202/29202.pdf


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