Dealing with the three aspects of MS
View(s):It was on multiple sclerosis (MS) that Dr. Ruwani Gunawardane, a Visiting Professor of the University of Maryland, United States of America, focused on at a recent lecture delivered at the surgical auditorium of the National Hospital in Colombo.
Dr. Ruwani Gunawardane
Dealing with the three aspects of ‘Why does MS exist?’, ‘What we can do to reduce it?’ and ‘Disease modifying therapies’, she said that MS is thought to be “an immune-mediated disease of the central nervous system which is made up of the brain, spinal cord and optic nerves”.
According to research, MS occurs when certain types of lymphocytes (white blood cells) get the wrong message and attack the protective sheath (called myelin) that surrounds the nerve fibres in the brain. “When the myelin is attacked, it causes disruptions in the transmissions from the brain to the body, which can result in many different symptoms,” she said, adding that MS is a disease resulting in chronic, inflammatory demyelination in the central nervous system. Pharmacologic management of MS has focused on modulating the immune system to alter the course of MS pathology.
Reiterating that early treatment slows the rate of disease progression, she explains that the goal of MS therapy is to slow disease progression in the three key clinical manifestations – slow the rate of disability progression, reduce the number of relapses and reduce the number and volume of central nervous system lesions. “No two people have exactly the same experience with MS. The symptoms and disease progression are unique to each person.”
Delving into the four patterns of MS which are Relapsing-Remitting MS (RRMS), Secondary Progressive MS (SPMS), Primary-Progressive MS (PPMS) and Progressive-Relapsing MS (PRMS), Dr. Gunawardane says that if left untreated around 50% of RRMS patients progress to SPMS within 10 years.
The approved disease-modifying therapies in the USA are oral therapies (1 to 2 pills of various sizes per day), injections (up to seven injections per week) and intravenous (IV) infusion (once every four weeks), she says.
Elaborating Dr. Gunawardane says:
Teriflunomide appears to reduce the number of overactive T and B cells available to attack the nerves. Usually these cells help the body to fight disease, but in MS, they get the wrong message and attack the central nervous system. Although the exact way in which teriflunomide works is not known, research suggests that it blocks the reproduction of overactive T and B cells that may cause inflammation. Research had shown that there was a significant impact on sustained disability progression with teriflunomide, while the majority of patients also remained relapse-free at week 108 with the medication and there was a significant reduction in GD-enhancing T1 lesions. The most common side-effects included abnormal liver test results, hair thinning or loss, diarrhoea, flu, upset stomach and a burning or prickling feeling of the skin.
The first US Food and Drug Administration (FDA)-approved oral drug for relapsing forms of MS was fingolimod. Research has shown that it reduces annualized relapse rates, reduces MRI lesions and also disability progression. Fingolimod reduces relapses at year 1, which is sustained over two years. It also significantly reduces new or enlarging T2 lesions. While fingolimod may increase the risk of infections, some serious in nature, it is contraindicated in patients with recent myocardial infarction, unstable angina, stroke, transient ischaemic attack etc.
Dimethyl fumarate has been approved by the FDA for people with relapsing MS. It helps to cut relapses, delay physical disability progression and slows the development of brain lesions.
Although earlier MS mainly affected Caucasians, it now seems to have gone to other parts of the world, says Dr. Gunawardane, which may be attributable to viral infections, lifestyle changes, cold weather and stress.
She says her advice to patients is: Relieve stress, exercise and take your vitamins.