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What is Multiple Sclerosis?
Multiple Sclerosis (MS) is an immune-mediated (autoimmune) inflammatory disease that attacks myelinated axons in the central nervous system (CNS), including brain, spinal cord, and optic nerves. In most cases the disease has a relapsing-remitting pattern, with episodic neurological deficits which completely or partially resolves in time. In progressive forms of multiple sclerosis, patients will experience gradual progression and deterioration of functions.
The prevalence of Multiple Sclerosis has been estimated to be proximately 400,000 patients in the US, which is estimated at 1 per 1000. However, the proximate number of Multiple Sclerosis patients in the world is about 2.3 million. The disease is more common in women. The male to female ratio is approximately 1:2. MS in most cases is diagnosed in persons between the ages of 25 and 45; however, it can occur at any age. The average age of diagnosis of MS in the United States is approximately 30 years old. The disease is presented in all part of the world and in every race. Worldwide, Multiple Sclerosis has higher prevalence in the areas of the world in latitude such as Northern Europe, North America, and Canada.
Types of MS
Multiple Sclerosis has been categorized to four different types by clinical presentation:
- Relapsing-remitting MS: The most common type of Multiple Sclerosis. It presents with episodic neurological symptoms (relapses) followed by periods of complete or partial recovery (remission). Approximately 65 to 70 percent of MS patients presents with this type at the time of diagnosis.
- Secondary progressive MS: It presents with gradual progression of the previously relapsing-remitting symptoms. This type of MS accounts for approximately 20 to 30 percent of overall Multiple Sclerosis.
- Primary Progressive MS: This type of MS presents with gradual progression of the symptoms from the begging without having episodes of relapsing-remitting. This represents approximately 5 to 10 percent of overall MS population.
- Relapsing-Progressive MS: This type of Multiple Sclerosis is a sub type of relapsing forms of MS which represents with both episodic relapses as well as gradual progression of the disease.
What is a Relapse?
A relapse or exacerbation in Multiple Sclerosis defines as new neurological symptoms which last for at least 24 hours or previous neurological symptoms which had completely resolved and now it has reoccurred and has lasted at least 24 hours. By contrast Psudo-exacerbation or psudo-relapses are neurological symptoms which have other underlying causes such as infections (e.g. urinary tract infection, upper respiratory infection, etc.), heat and physical and psychological stressors.
Possible Causes of MS
The cause of MS in not known yet. It is likely to involve attack of an auto-immune system against the Central nervous system (CNS). It is thought to be triggered in a genetically susceptible individual by a combination of possible viral infection and one or more environmental factors and therefore it has been labled as Neuro-immuno-genetic disease. There are also geographical theories in the incident of the Multiple Sclerosis which favors the higher incidents of MS in northern hemisphere and areas further from the equator. As part of the immune attack on the central nervous system, myelin (the fatty substance that surrounds and protects the nerve fibers in the central nervous system) and subsequently the nerve fibers themselves called axons are damaged. The damaged myelin forms scar tissue (sclerosis), which gives the disease its name. When any part of the myelin sheath or nerve fiber is damaged or destroyed, nerve impulses traveling to and from the brain and spinal cord are distorted or interrupted, producing the variety of symptoms that can occur.
Symptoms of Multiple Sclerosis are variable. Spectrum of the symptoms could be mild such as numbness or sever such as paralysis and loss of vision. There are extensive symptoms which fall in between the above spectrum. MS symptoms could include but not limited to:
- Visual problems
- Cognitive dysfunction
- Psychological issues such as depression, anxiety
- Bowel and bladder problems
- Sexual dysfunctions
- Heat intolerance
- MS Hugs
- Difficulty with balance and ambulation
The progress, severity, and specific symptoms of MS are unpredictable and vary from one person to another.
Diagnosis of Multiple Sclerosis is made based on the extensive and expert consideration of current and prior neurological symptoms/episodes, in conjunction with the result of diagnostic tools such as comprehensive physical examinations, MRIs of brain and spinal cord, exclusionary laboratory work-up, electro-physiological testing such as Visual Evoke Potential (VEP) and in some cases results of the cerebro-spinal fluid studies (CSF). However, based on the current and new diagnostic criteria (Revised McDonald’s Criteria) clinical history, and MRI Imaging in most cases are sufficient to make diagnosis. Proper evaluation by neurologist expert in Nuero-immunology and Multiple Sclerosis is recommended.
Over the past 3 decades there has been great deal of advances in diagnosis and treatment of Multiple Sclerosis. Up to the turn of the century, steroids and immunosuppressive medications were the only treatment modalities available. However, over the past 26 years there have been 20 FDA-approved medications for MS and 3 for NMOSD have become available in order to reduce relapses, MRI activities, and slow down the progression of the disability in MS and NMOSD. These medications as group have been labeled as Disease Modifying Therapies (DMTs). Below is the chronological list of all the FDA-approved medications available to the patients with Multiple Sclerosis and NMOSD. It needs to be understood that proper discussions with your physicians regarding pros and cons, risks and benefits as well as appropriate monitoring of each of these medications are necessary prior to start these or any other medications.
FDA Approved Medications for Multiple Sclerosis (updated 10/2020)
Betaseron – (1994) sub-Q injections, every other day
Avonex – (1996) Intra-muscular injections, weekly
Copaxon – (1996) Sub-Q injections, daily
Rebif – (2002) Sub-Q injection, three times a week
Novantrone – (Mitoxantrone) IV infusion, every 3 months (Note: sever restrictions)
Tysabri – (2006) IV infusion, every four weeks
Extavia – (2010) (Generic Betaseron) sub-Q injections, every other day
Gilynea – (2011) Oral, Daily
Aubagio-(2012) Oral, Daily
Tecfidera (2013) Dimethylfumerate, Oral, twice a day
Alemtuzimab (2014) (Campath, Lamtrada) , IV infusions 5 Days in 1st year & 3 days in 2nd year
Copaxone 40 mg (2014), Sub-Q 3 times a week
Plegridy- (2014) Pegylated Interferon, Intramuscular, every 2 weeks
Glatopa – 2015 Generic Copaxone (20 mg) & 2018 (40 mg)
Ocrelizumab (2017) (Ocrevous). IV infusions every 6 Months
Mayzant- 2019 (Siponiomod) oral, Daily
MevanClad- 2019 (cladribine), Oral, 10 daily doses per year. Year 1 & 2
Vumerity- 2019 (Diroximal Fumerate), Oral , 2 tabs, Twice daily
Zeposia- 2020 (Ozanimod), Oral, Daily
Kesimpta-2020 (Ofatumumab), Sub Q, Monthly
Bafiert-2020 (Monomethyl Fumerate), Oral twice daily
Treatment in the pipeline
Please note that the following medications are not currently available for prescription or general use.
(This section is under review to be completed soon)
FDA approved medications for NMO (neuromyelitis Optica) (updated 10/2020)
Solaris – 2019 (Euclizumab), IV, Every 2 weeks
Enspryng – 2020 (Satralizumab-mwge), Sub Q, Monthly
Uplizna – 2020 (Inebilizumab-cdon), IV , Every 6 months
The following complimentary modalities have been shown to be in part helpful to some individuals and to a certain degree in alleviating neurological symptoms. However, it needs to be understood that the potential results are extremely individual based and variable. It also needs to be noted that these remedies if any must be implemented in conjunction with FDA-approved DMTs for MS and not in lieu of. Please consult with Dr. Bandari before making decision in implementing any.
- Aqua therapy
- Equine therapy
- Herbal remedies
Latest in MS
Advances in understanding the pathology, the underlying causes and treatment modalities for Multiple Sclerosis are ongoing. The following are the list of some of latest understanding and forecast of some of the future modalities in treatment of Multiple Sclerosis.
What to Avoid
Despite of all and scientific knowledge regarding Multiple Sclerosis the underlying auto-immune process and availability of FDA-Approved medications, which have proven to be effective in treatments of the disease, there are still few fables and unfounded believes and unorthodox, unconventional, and in most cases flat out dangerous modalities which in most cases have no scientific basis. Unfortunately, some MS patients fall into the mental trap and inadvertently have caused more harm to themselves by prescribing to some of these unregulated managements. The following is the list of some of these unregulated modalities:
- Bee stings
- CCSVIs (Chronic Cerebrospinal Vascular Insufficiency Syndrome)
- Unregulated stem cell injections / infusions