Treatment of patient with multiple sclerosis (MS) depends on patient's clinical status and disease course.
On the basis of the available knowledge and experience, we can distinguish 4 major aspects of MS patients' therapeutic management:
Treatment of relapses [may be considered as symptomatic treatment].
It concerns mainly patients with relapsing-remitting MS (RRMS). Relapse (i.e.: occurrence of new or worsening of previous neurological symptoms resulting in patient's status deterioration by at least 1 point according to EDSS score; symptoms persist over 24 hours and are not associated with infection) diagnosis is a condition for this kind of therapy administration. Expanded Disability Status Scale (EDSS) is used for MS patient's disability assessment. It allows for reliable comparison of patients' status, disease progression assessment; thus it facilitates selection of appropriate therapeutic decisions. This is a 10-point scale, where 0 indicates normal motor skills, and 10 indicates patient's death.
Before therapy initiation exclusion of potential infection sites is required. Infection may impact patient's neurological status and may potentially simulate relapse. Moreover, use of glucocorticosteroids in patient with an on-going infection poses a potentially serious health- and life-threatening risk.
It was shown that glucocorticosteroids use has short-term, however beneficial, impact on patient's functional improvement rate.
However, during therapy a close monitoring of patient's health status is required due to multiple side effects of such a treatment. In case of important adverse events or infection occurrence while on treatment, attending physician should verify therapeutic indications, and withdraw an eventual decision on drug administration, if necessary.
Often, symptomatic treatment does not differ significantly from the management used in case of other than MS cause triggering a given symptom. Usually, the attending physician makes decision on treatment type based on patient's complaints, anamnaesis and entire clinical picture.
The most frequent, patient-reported symptoms are as follows: spasticity, tremor, pain, mood disorders (depression), chronic fatigue, lower urinary tract disorders, sexual dysfunction.
In treatment of the above symptoms, a physiotherapy and psychotherapy, except of medical treatment, are used. Providing a complexed support to MS patient is very important, and results from the fact that use of one form of therapy is often insufficient.
Opportunities of MS therapy
Therapeutic aims in the treatment of multiple sclerosis may vary, depending on the individual patient. MS relapses and symptoms “undergo treatment” by modifying natural course of the disease. There are immunomodulating drugs - that modify natural course of the disease by reducing the number and severity of the disease relapses and immunosuppressive drugs - affecting the immune system, less safe, but often more effective. Other drugs that combat specific symptoms and useful during a disease relapse to stop the inflammatory process that destroys the central nervous system, are also used.
The most important therapeutic aim is to modify the disease course - inhibit its progression, limit occurrence of relapses and formation of new demyelinating lesions. Scale of the problem is enormous thus investigations of new molecules are very extensive. Up to 2006 there were only four drugs useful in the MS therapy. Today there are 11 such molecules and another ones, mainly oral drugs, are under investigation.
Initially the basic challenge was to reduce incidence of relapses and limit the signs and symptoms. When it was achieved, the search continued for methods of inhibiting of the disease activity. This often has also become possible. Currently investigations are ongoing to reverse the existing changes in the nervous system.
The time between diagnosis and initiation of therapy is of utmost importance. The sooner immunomodulating therapy is started, the less irreversible lesions develop.
Treatment of multiple sclerosis in Poland is based on two lines:
1. first line of therapy - first line immunomodulating therapy that is the initial therapy - usually interferons and glatiramer acetate are used - the therapy is safe, but its effectiveness varies;
2. second line of therapy - second line treatment, more effective, initiated when first line therapy is unsuccessful and when severe MS develops rapidly - basic drugs include natalizumab, fingolimod.
Injection drugs are the medications that have been known and used for the longest time. For the past several years patients have had access - although not in Poland - to oral drugs (e.g., dimethyl fumarate) that markedly facilitate living with a chronic disorder. There are ongoing investigations of new molecules, also ones that reverse the demyelination process.
Immunosuppressants do not have a completely proven efficacy in MS treatment (small number of clinical trials, marked cytotoxicity), therefore they are mainly used as so called rescue therapy in patients with an important health status deterioration; they inhibit function of the immune system.
In case of patients with primary progressive MS, currently no drug with a proven effect on patient's general health and neurological status was found. In this group of patients, a symptomatic treatment is currently used.
In long-term attempts aiming to find an effective MS therapy, many agents with less or more important impact for the disease course were used. Some of those agents were withdrawn from clinical trials due to their high toxicity and important side effects occurrence. Recently, an important progress in MS therapy raises big hopes for bright future.