Multiple sclerosis - the treatment options
Multiple sclerosis (MS) is a chronic, inflammatory disease of the central nervous system (CNS), characterised by inflammation and demyelination of white matter in the brain and spinal cord.1 Multiple areas of scar tissue (sclerosis) form along the nerve fibres, slowing or blocking the transmission of signals to and from the brain and spinal cord, so that various functions, including movement and sensation, may be lost.2 The disease, therefore, is manifested in physical symptoms (relapses and progressive disability), CNS inflammation and cognitive dysfunction. There is great inter- and intrapatient variability of symptoms. MS-related symptoms are shown in Panel 1 (p18).3
MS usually follows a relapsing-remitting course in the early stages of the disease, ie, an acute exacerbation of the disease followed by complete, or near complete, remission. This is known as relapsing-remitting MS (RR-MS). Over time, the disease may enter an irreversible progressive phase, where recovery after a relapse is reduced, and patients have more disabling symptoms. This is known as secondary progressive MS (SPMS). There are two other main types of MS — primary progressive (PP-MS), where the disease progresses without relapses, and benign MS, where full recovery occurs after a relapse. A rare category is progressive relapsing disease (PR-MS), which has a similar prognosis to PP-MS.
The three pharmacological approaches to the treatment of MS are management of acute exacerbations, prevention of disease progression, and treatment of chronic symptoms.
An acute deterioration in the neurological state of the patient can arise from an episode of inflammatory demyelination, but can also be caused by other conditions, including concurrent infection (especially urinary tract infection), electrolyte imbalance, fever or drug intoxication.4
Most relapses show a degree of spontaneous recovery, but treatment is advised for those relapses that have a severe impact on function. Steroids are the treatment of choice for relapses, usually methylprednisolone 1g daily by intravenous infusion for three days. Alternatively, 500mg daily for five days is sometimes given.
Anecdotally, patients report improvement with low dose oral prednisolone for less severe relapses. However, based on the experience of the optic neuritis treatment trial, only high doses of oral steroids, similar to IV doses, reduce the duration of relapses.5 Subsequent studies, also performed in optic neuritis, have shown that equivalent oral doses of steroids can be equally effective.6
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Citation: Hospital Pharmacist URI: 10976496
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