How to treat multiple sclerosis

While there is no definitive treatment for multiple sclerosis (MS) at this time, experts feel that patients with MS should undergo aggressive disease-modifying regimens to help suppress the disease and its effects. As well, a host of other medications should be used during relapses to lessen specific symptoms. Early diagnosis and intervention are thought to help the symptoms of MS and slow its progression.

There has been an explosion of disease-modifying medications that help modulate the body’s immune response to central nervous system (CNS) myelin. These medications try to decrease the number and degree of relapses and slow MS progression.

There are multiple classes of disease-modifying drugs for MS. For example, immunomodulators regulate the response of the immune system and include interferons, various monoclonal antibodies, sphingosine-1-phosphate receptor modulators, and other agents.

Immunosuppressants, another class of medications that are less commonly employed for treating MS, are generally antineoplastic agents. These may include methotrexate, mitoxantrone, cyclophosphamide, azathioprine, and others.

It is important to recognize that immunomodulating and immunosuppressing medications affect the immune system and have significant implications for pregnancy and various infectious diseases. These medications will need to be followed closely for their efficacy and related side effects. If an agent is ineffective, other agents with different mechanisms of action should be considered.

During an acute relapse, and for longer-term symptoms of MS, multiple agents are often employed:

• Corticosteroids
• Amantadine
• Skeletal muscle relaxants
• Anticonvulsants
• Antidepressants
• Narcotics and nonsteroidal anti-inflammatory drugs (NSAIDs)
• Antispasmodics, laxatives, and antidiarrheals

Corticosteroids

Corticosteroids such as dexamethasone, methylprednisolone, or prednisone are employed to hasten recovery and dampen symptoms.

When prescribing corticosteroid medications, consider a short course followed by a dosage taper. Remember, these agents can inhibit adrenal function, and extended use will need a careful and prolonged medication taper. An endocrinology consult should be initiated to help guide the tapering of corticosteroids. Note that patients who are adrenally suppressed may need stress doses of corticosteroids, or higher dosages during times of stress such as when infected or physiologically stressed.

Amantadine

Another consideration for the pharmaceutical management of MS is amantadine. Amantadine is a dopamine agonist that can be helpful for profound fatigue.

Skeletal muscle relaxants

You may also want to consider skeletal muscle relaxant medications such as baclofen, dantrolene, botulinum toxin, tizanidine, or benzodiazepines for your patients with MS. These medications treat MS-related muscle spasticity.

Anticonvulsants

Anticonvulsants such as gabapentin, carbamazepine, pregabalin, topiramate, and phenytoin can be useful for treating MS-related pain, paresthesia syndromes, and tic-like facial pain. Unfortunately, pain is a significant component of the clinical course for many MS patients. Remember, demyelination may affect the sensory system as well as other regions of the central nervous system, which results in atypical and often vexing pain syndromes.

Antidepressants

Depression is very common in MS, and your patient may benefit from the use of antidepressants such as selective serotonin / norepinephrine reuptake inhibitors. Some antidepressants, such as duloxetine, are also effective in managing MS-related pain.

Narcotics and NSAIDs

It is important to try to avoid narcotic medications in the treatment of MS-related pain syndromes. Simple NSAIDs are often quite effective.

Antispasmodics, laxatives, and antidiarrheals

Bladder and bowel dysfunctions are common in MS. Be prepared to consider various urinary antispasmodic agents, laxatives, and antidiarrheal medications for patients presenting with these symptoms.

MS is rarely fatal by itself, but complications of severe neurological debilitation can result in death. As such, MS is believed to shorten the average life span by five to ten years. Thankfully, with modern medical intervention and aggressive long-term management, lifespan in patients with MS seems to be increasing!

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