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An Overview of MS Symptoms and Medications

   
 
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Using information from the National MS Society’s website -- a valuable source for information about diagnosis, management and life with multiple sclerosis (MS) --the October 2015 MS/Cancer conference call discussed MS diagnosis, symptoms and medication. Here is a summary of our discussion. This information can be found in more detail on the national website at www.nationalmssociety.org/What-is-MS/Types-of-MS/Primary-progressive-MS/Research-in-Primary-Progressive-MS.

 Both the National MS Society and the American Cancer Society sponsor the MS/Cancer call. 

Criteria for a diagnosis of MS

 No symptoms, physical findings or laboratory tests can by themselves determine if a person has MS. Different approaches can determine if a person meets the long-established criteria for a diagnosis of MS and to rule out other possible causes of symptoms the person is experiencing. These strategies include a careful medical history, a neurologic exam and various tests including magnetic resonance imaging (MRI), evoked potentials (EP) and spinal fluid analysis.

To make a diagnosis of MS, the physician must meet these three criteria:

  • ·      Find evidence of damage in at least two separate areas of the central nervous system (CNS), which includes the brain, spinal cord, and optic nerves
  • ·      Find evidence that the damage occurred at least one month apart
  • ·      Rule out all other possible diagnoses.

The four types of MS are as follows:

Relapsing-remitting MS (RRMS)

RRMS is the most common disease course and is characterized by clearly defined attacks of worsening neurologic function. These attacks, which are also called relapses, flare-ups or exacerbations, are followed by partial or complete recovery periods (remissions), during which symptoms improve partially or completely and there is no apparent progression of disease. Approximately 85 percent of people with MS initially are diagnosed with relapsing-remitting MS.

Secondary-progressive MS (SPMS)

The name for this course comes from the fact that it follows after the relapsing-remitting course. Most people who initially are diagnosed with RRMS will eventually transition to SPMS. This means that the disease will begin to progress more steadily although not necessarily more quickly, with or without relapses.

Primary-progressive MS (PPMS)

PPMS is characterized by steadily worsening neurologic function from the beginning. Although the rate of progression may vary over time with occasional plateaus and temporary, minor improvements, there are no distinct relapses or remissions. About 10 percent of people with MS are diagnosed with PPM.

Progressive-relapsing MS (PRMS)

PRMS, the least common of the four disease courses, is characterized by steadily progressing disease from the beginning and occasional exacerbations along the way. People with this form of MS may or may not experience some recovery following these attacks; the disease continues to progress without remissions

Medications

The following U.S. Food and Drug Administration (FDA)-approved disease-modifying agents reduce disease activity and disease progression for many people with relapsing forms of MS, including relapsing-remitting MS, secondary-progressive and progressive-relapsing MS in those people who continue to have relapses.

  • Injectable medications
    • Avonex (interferon beta-1a)
    • Betaseron (interferon beta-1b)
    • Copaxone (glatiramer acetate)
    • Extavia (interferon beta-1b)
    • Glatopa (glatiramer acetate, a generic equivalent of Copaxone 20mg dose)
    • Plegridy (peginterferon beta-1a)
    • Rebif (interferon beta-1a)
  • Oral medications
    • Aubagio (teriflunomide)
    • Gilenya (fingolimod)
    • Tecfidera (dimethyl fumarate)
  • Infused medications
    • Lemtrada (alemtuzumab)
    • Novantrone (mitoxantrone)
    • Tysabri (natalizumab)

In a National MS Society Learn on Line video, Dr. Benjamin Segal discusses the progressive form of MS. Dr. Segal is a professor at The University of Michigan and directs the Multiple Sclerosis Center and at the Holtom-Garrett Program in Neuroimmunology. The video can be found on the MS National Society website at http://www.nationalmssociety.org/What-is-MS/Types-of-MS/Primary-progressive-MS/Research-in-Primary-Progressive-MS.

Segal said in the video that, “Progressive MS begins with neurological symptoms that can vary from attack to attack.” He said that the patient’s health may go back to his or her base line. Then the patient may enter a second stage and get gradually worse with a particular symptom. Most patients experience a slow, steady decline secondary progression. Dr. Segal said, “Tempo is important in terms of disability they experience.”

Segal said that many MS patients might not be able to say when their symptoms got worse. They might not be able to pinpoint the date but they know they are not as well.

Segal discussed chemotherapy treatment for patients. He said, “Some of my patients see benefits from intermittent steroid treatments. Sometimes we will give a steroid once a month and this seems to help stabilize patients. Not everyone responds and this has not been proven in rigorous clinical trials because they haven’t been done.”

However, Segal said a great deal of research going on such as developing drugs to help the body recover from damage from progressive MS; to how the nervous system may block nerve cells from regenerating; and looking into how to interfere with that process to allow the nerve cells to regrow.

Clinical trials

The National MS website reports that people who have received a diagnosis of PPMS are often frustrated by the relatively small number of clinical trials in PPMS compared to the large number in RRMS. MS clinicians and researchers share this frustration and are working to increase the number of trials of treatments for PPMS. Some of the obstacles are as follows:

  • The disease modifying medications currently used to treat relapsing forms of MS primarily target inflammation in the central nervous system. Because inflammation plays a much smaller role in PPMS than in relapsing forms of MS, these medications do not seem to be as effective in PPMS, which means that new treatment targets need to be identified.
  • In PPMS, there is a lack of easily identifiable outcomes to measure in clinical trials. In the trials for the approved disease-modifying therapies, investigators looked at outcomes such as number of relapses and number of new lesions seen on magnetic resonance imaging to determine if people who received the treatment had lower numbers than those who received a placebo. The outcome measurements do not adequately quantify disease progression in the PPMS group.
  • Disease progression in PPMS can be quite slow, making the ability to identify an effect on progression difficult in a two- or three-year trial.

Researchers are working to understand why some people experience aggressive worsening of MS and others experience a milder course, and to identify other ways to measure the changes that occur in PPMS so that they can more easily test potential treatments.

For more information, go to www.nationalmssociety.org.

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