MULTIPLE SCLEROSIS

DIAGNOSIS AND TREATMENT OF MULTIPLE SCLEROSIS

1. What is multiple sclerosis?

Multiple sclerosis is a demyelinating disease of central nervous system-CNS (brain and spinal cord), which is characterized by involvement of “multiple” parts of CNS.

The disease is also characterized by remissions (improvement of symptoms) and relapses (occurrence of new symptoms) over a period of time, causing “multiple” episodes of symptoms.  

Multiple sclerosis is an autoimmune disease, which means the antibodies produced in the body attacks own healthy tissues.

2. What is the meaning of demyelination or demyelinating illness?

Nerves in central nervous system are like “electric wires”, that is, they have a central core surrounded by an insulation or covering. This covering of the nerves is called “myelin sheath”.

A disease, where the myelin sheath is affected or damaged is called a demyelinating disease or illness, and the process is called as demyelination. Multiple sclerosis is one of the most common demyelinating diseases of the CNS.

3. Who are the common people affected by multiple sclerosis?

·        Multiple sclerosis is commonly seen between the ages of 10 and 60 years, which means, it is uncommon in children below 10 years and those adults who are above 60 years of age.

·        Multiple sclerosis is typically more common in young women (between the ages of 18-36 years),

·        Multiple sclerosis is seen all over the world, probably more common in the West, as compared to Asian countries.

·        Also, the severity of multiple sclerosis seems to be lesser in Asians, leading to lesser degrees of disability, which has led some people to label Asian multiple sclerosis as relatively “benign form” of multiple sclerosis.

4. What are the common symptoms of multiple sclerosis?

Common symptoms of multiple sclerosis include:

• Sudden onset diminished vision in one or both eyes, which may get worse over a few days,
• Numbness of arm or leg on one or both sides of body,
• Weakness of arm or leg on one or both sides of body,
• Imbalance while walking,
• Bladder symptoms,

Less common symptoms of multiple sclerosis include

·        Memory disturbances,

·        Seizures or fits,

·        Depression

It is important to note that a patient with multiple sclerosis may have only one or more than one symptom described above at one point of time, or different symptoms may occur during multiple episodes of the disease.

5. How is the diagnosis of multiple sclerosis confirmed?

A person who has one or more symptoms suspicious of multiple sclerosis should consult a neurologist. A neurologist would take history and do a clinical examination to ascertain the number of episodes of illness, and also to identify the affected the parts of central nervous system.

After that he would order for investigations to confirm the diagnosis of multiple sclerosis.

6. What are the important investigations for confirming a diagnosis of multiple sclerosis?

• MRI (Magnetic resonance imaging) of brain and spinal cord- this is the most important investigation. MRI shows the involvement of different parts of brain and spinal cord. The white matter of brain and spinal cord are typically affected in multiple sclerosis. The diseased part of brain and spinal cord are also referred to as “lesions” or “plaques”. A new or active lesion shows enhancement on MRI with contrast dye injection. In addition, there may be swelling around the active lesions. MRI is also able to distinguish new versus old lesions, and is useful to monitor the disease progression or improvement and also the effectiveness of treatment.

• CSF (cerebrospinal fluid) analysis- CSF is removed by lumbar puncture (LP) by inserting a needle in lower back. In multiple sclerosis, the CSF protein is elevated; however, the number of white blood cells (WBCs) is either normal or only slightly elevated. CSF sugar is often normal. CSF is also tested for the presence of oligoclonal bands (OCBs), the presence of which indicates an active disease.
• Evoked potential studies may be ordered to look for involvement of optic nerve (visual evoked potential or VEP) or spinal cord (somatosensory evoked potential).
• Blood tests (such as ANA, Anti-dsDNA, ANCA, etc) may be ordered to exclude other diseases that can mimic multiple sclerosis.

7. What are the current treatment options for multiple sclerosis?

Treatment of multiple sclerosis can be divided into two categories- treatment of acute episodes and treatment to prevent future relapses of disease.

Treatment for acute episodes:

Steroid injections are the preferred treatment options. The drug of choice is methylprednisolone given as injections in the veins over 3-5 days. Then, steroid tablets are given for 15-20 days.

Treatment to prevent relapses of disease:

The most preferred treatment is interferon injections (such as avonex, relibeta and rebif in India). Avonex and relibeta are given as injections in the muscles, once a week, whereas rebif is given as injections underneath the skin three times a week.

Other FDA-approved treatment options to prevent relapses of disease in multiple sclerosis are:

1. Glatiramer acetate (copaxone)- given as injection underneath the skin, once a day.

2. Fingolimod- oral capsule (0.5 mg) once daily

3. Mitoxantrone- given as infusion in the vein, every three months (maximum 8-12 doses over two-three years),

4. Natalizumab (tysabri)- given as infusion in the vein, once every four weeks.

5. Dimethyl fumerate (tecfidera)- twice a day oral capsules.

6. Teriflunomide (Aubagio)- once daily tablets. 

 8. Is Multiple sclerosis curable?

As of today, there is no cure for multiple sclerosis. However, with current treatments, the disease can be kept under control and new relapses can be prevented.

9. Is multiple sclerosis always disabling?

Multiple sclerosis does cause disability in a significant number of people. However, more than two-thirds of patients suffering from multiple sclerosis are independent for their activities of daily living and are gainfully employed in a job. The good outcome depends on proper treatment as well as physical & occupational therapies.

10. Is multile sclerosis contagious or genetic?

Multiple sclerosis is not contagious and does not get transmitted from one affected person to another.

There may be genetic predisposition to get multiple sclerosis but it is not a genetic disease in a strict sense, as most patients with multiple sclerosis do not give a positive family history.

11. Is multiple sclerosis fatal or lethal?

In more than 95% of patients with multiple sclerosis, it does not lead to death. However, in a minority (less than 3%) it may lead to death either due to the direct effect of the severe disease or another complication such as pneumonia or deep vein thrombosis.

I hope this article is useful for hundreds of patients with multiple sclerosis as well as their caregivers. In addition, if someone is looking for information on multiple sclerosis (MS), it should be useful.

For any additional information, please email me at drsudhirkumar@yahoo.com

DR SUDHIR KUMAR MD (Internal Medicine), DM (Neurology)

Senior Consultant Neurologist

Apollo Hospitals, Hyderabad, India

Phone: 0091-40-23607777/60601066

drsudhirkumar@yahoo.com