• Treatment

    The treatment of patients with MS includes:
     

     

    Acute Treatment of Exacerbations  

    Intravenous methylprednisolone (Solumedrol) is the most common drug used to treat symptoms during an exacerbation. Solumedrol is typically given for three to seven days, and oral steriod tapering with prednisone or a medrol dosepak, may follow its administration. Possible side effects of this treatment include the following:

    • High blood sugars
    • High blood pressure
    • Gastrointestinal bleeding (ulcer)
    • Increase risk of infection
    • Osteoporosis
    • Mood swings

    For patients with severe exacerbations who do not experience recovery following a conventional treatment course with IV steroids, plasma exchange can be used. Plasma exchange is a process that involves withdrawing blood from the patient, removing and replacing the liquid (plasma) portion, and then transfusing the blood--with all red and white blood cells--back into the patient. Although its mechanism of action is not completely understood, plasma exchange is beneficial to MS patients because the process removes the circulating antibodies thought to be responsible for the disease.

    Back to Top  

    Preventive Treatment of Relapses

    Preventive treatment of MS involves the use of an immunomodulator and/or monoclonal antibodies. Both types of drugs influence the immune system to end an immune attack.

    Immunomodulators

    There are two major types of injectable immunomodulator agents: interferon beta and glatiramer acetate:

    Interferon Beta   

    • Interferon beta-1a
      • Avonex: a dose of 30 micrograms (mcg) is administered intramuscularly once per week
      • Rebif: a dose of 22 to 44 mcg is given subcutaneously three times per week  
       
    • Interferon beta-1b
      • Betaseron: a dose of 0.25 milligrams (mg) is administered subcutaneously every other day

      All Beta-interferons can be administered with an autoinjector or pen. Side effects can be flu-like symptoms ameliorated with pre-medication. Liver function, blood cell counts, thyroid function are monitored.

    Glatiramer Acetate (Copaxone)

    Side effects of this medication may include injection site reaction, chest pain and lipoatrophy (loss of fat under the skin, resulting in small dents). A dose of 20 mg is administered subcutaneously on a daily basis or 40 mg three times weekly.

    There are three major types of oral immunomodulator agents: fingolimod, teriflunomide, and dimethyl fumarate.

    Fingolimod (Gilenya)

    Fingolimod is a 0.5 milligram (mg) oral tablet taken once daily. First dose cardiac monitoring is required. The medication is typically not prescribed to those with cardiac conditions. The lymphocyte count (a type of white blood cell) will decrease as a result of the medication. An initial eye exam is required. Liver function is monitored.

    Teriflunomide (Aubagio)

    Teriflunomide is a 14 milligram (mg) oral tablet taken once daily, with 7 milligram (mg) dosing regimen also available. This medication must be completely cleared from the patient prior to pregnancy, and birth control must be used. It can cause transient nausea, diarrhea, and hair loss. Patients who want to take teriflunomide must be screened for tuberculosis. Liver function is monitored.

    Dimethyl Fumarate (Tecfidera)

    Dimethyl Fumarate is 120 millgram (mg) oral tablet taken twice daily for the first week of treatment, and then patients are to take 240 milligram (mg) doses, twice daily. This medication can cause initial flushing, rashes, nausea, vomitting, and diarrhea.

    Monoclonal Antibodies

    MS nurse and patient discuss medicationsMonoclonal antibodies are produced in cell culture systems and are designed to bind to specific receptors and alter abnormal cellular responses. There are currently several types of monoclonal antibodies being studied for treatment of the relapsing-remitting and primary-progressive forms of MS.

    Natalizumab (Tysabri) is the only monoclonal antibody approved for relapsing-remitting multiple sclerosis. Natalizumab is thought to selectively block leukocytes from crossing the blood-brain barrier, thus potentially inhibiting the inflammation from occurring in the central nervous system. This medication is given intravenously once a month, is usually well tolerated, and is very effective.  Tysabri is currently approved only as a monotherapy. There is a risk of progressive multifocal leukoencephalopathy (a rare brain infection caused by the JC virus) in patients on Tysabri who have past exposure to the JC virus and antibodies to this virus in their system. One can be screened for the JC virus both prior to and when taking Tysabri.
    In order to receive Tysabri, patients are required to be enrolled on the Touch Program to ensure the highest level of safety. Dr. Camac, Dr. Chaves and Dr. Muriello are all Touch Program prescribers, and Lahey Clinic's Infusion Center in Burlington is a Touch Program Infusion Site.

    Rituximab (Rituxan) is another monoclonal antibody used off label in special circumstances.

    Immunosuppressors

    Common immunosuppressive agents used include  

    Intravenous:  

    • Mitoxantrone (Novantrone)
    • Cyclophosphamide (Cytoxan)

    Oral:  

    • Azathioprine (Imuran)
    • Methotrexate (Folex, Rheumatrex)
    • Mycophenolate mofetil (CellCept)

    MS patient undergoes IV infusionPossible side effects of these types of immunosuppressors include nausea, vomiting and increased risk of infection. Depending on the specific immunosuppressor used, other side effects may occur, including cardiotoxicity, hematuria, alopecia and liver toxicity. To prevent such side effects, frequent testing is performed, including monitoring of the white blood count, liver function tests, urine analysis and cardiac function testing.

    Back to Top  

    Symptomatic Treatment

    Fatigue: Approximately 80 to 97 percent of MS patients report fatigue. The drugs most frequently used to treat fatigue are amantadine (Symmetrel), modafinil (Provigil), activating antidepressants in some cases, and amphetamines in rare cases.

    Spasticity: This common MS symptom varies from mild muscle stiffness to severe, painful and uncontrollable muscle spasms. Spasticity occurs in 40 to 75 percent of MS patients. Pharmacological treatments include

    • Baclofen (Lioresal)
    • Tizanidine (Zanaflex)
    • Clonazepam (Klonopin)

    For patients who do not respond to, or who have side effects from, the oral treatment, Botox can be used. Stretching, aerobic exercise, and active and passive movements are important, and should be performed in conjunction with pharmacological treatment.

    Gait:  Fampridine SR (Ampyra) is a twice daily oral medication that can improve gait, both walking speed and endurance. There is a small risk of seizure.  

    Pain: Treatment of pain in MS patients is typically tailored to the underlying cause. For example, in treating neuropathic pain, a variety of medicines may be used:

    • Anticonvulsants (such as Neurontin, Topiramate, Zonisamide, Tegretal and Lyrica)
    • Serotonin-Norepinephrine Reuptake Inhibitors (like Cymbalta)
    • Tricyclic Antidepressants (like Amitriptyline)

    Depression: Depression is the most common mood disorder in MS patients. A combination of psychotherapy and pharmacologic treatment is usually recommended. Several prescription medications are used for the treatment of depression:

    • Selective serotonin reuptake inhibitors (SSRIs)
      • Fluoxetine (Prozac)
      • Sertraline (Zoloft)
      • Paroxetine (Paxil)
      • Citalopram (Celexa)
      • Escitalopram oxalate (Lexapro)
       
    • Atypical antidepressants
      • Venlafaxine (Effexor)
      • Bupropion (Wellbutrin)
       

    Neurogenic bladder: More than half of all MS patients experience urinary symptoms. The most common complaints include urinary urgency, frequency, hesitancy, urge incontinence and straining with incomplete emptying of the bladder. Recurrent urinary tract infections are also common in some MS patients and should be appropriately treated with antibiotic therapy.

    The following medications are used to treat urinary symptoms: 

    • Oral anticholinergics
      • Oxybutynin (Ditropan, Ditropan XL)
      • Tolterodine (Detrol, Detrol LA)
      • Imipramine (Tofranil)
       
    • Alfa - adrenergic blockers
      • Terazosin (Hytrin)
      • Clonidine (Catapres)
       

     Intermittent catheterization is necessary at times, as well. Botox injections can also be used in more severe circumstances in the treatment of neurogenic bladder. 

    Stem Cell Transplant 

    Stem cell transplant for treatment of MS patients is still experimental at this time.  There are two types of stem cell transplants that have been used.  

    • hematopoietic stem cell therapy 
    • mesenchymal stem cell therapy 

    Hematopoietic stem cell therapy 

    More than 600 MS patients treated with hematopoietic stem cell transplant have been reported in the literature, but unfortunately the results have been mixed, mostly due to the variety of techniques used and patient selection.  

    This is a very involved procedure consisting of 3 phases: 

    1. Collection of hematopoietic stem cells directly from the patient’s bone marrow or indirectly from the peripheral blood  
    2. Intense chemotherapy with the goal of destroying the patient’s overactive immune system. 
    3. Administration of the stem cells to the patient with the goal of reconstituting and possibly resetting a normal immune system.   

    This entire process can take 3-6 months.  Patients with very active relapsing remitting MS that have not responded to conventional treatments seem to benefit the most from this treatment. 

    Mesenchymal stem cell therapy 

    Mesenchymal stem cells are a subset of stromal cells mostly present in the bone marrow.  Pre-clinical studies with injections of mesenchymal stem cells in animals with experimental autoimmune encephalomyelitis (animal model for MS) showed decrease demyelination and axonal loss in those animals. It is believed that the mechanism of action of mesenchymal stem cells is by inhibiting immune responses and releasing neuroprotective molecules favoring tissue repair. A few studies have also provided some evidence that mesenchymal stem cells can engraft in the central nervous system and acquire a neural phenotype. 

    In 2009, the International mesenchymal stem cell transplantation study group was created and a phase II clinical trial MESEMS (MEsenchymal StEm cells for Multiple Sclerosis) was designed. This ongoing study is evaluating the safety and efficacy of autologous intravenous mesenchymal stem cells in patients with active multiple sclerosis.  This study should be completed by September 2014.  

    Neuropsychological Assessment

    Many patients who are being seen in the MS Center are also being referred for a neuropsychological evaluation. The purpose of a neuropsychological evaluation is to evaluate the your thinking abilities, your ability to pay attention, concentrate, learn, remember, understand language, express yourself, plan, problem solve and organize, as well as your ability to see and manipulate information. The purpose is also to:

    • Provide a profile of strengths and weaknesses to assist with treatment planning, guide rehabilitation, and/or educational and vocational services.
    • Document changes in thinking abilities/functioning since prior examination.
    • Clarify what compensatory strategies may be helpful.

    A screening evaluation may last between one and two hours, while a more comprehensive evaluation may take as long as four hours. The type of evaluation largely depends on the difficulties you may be experiencing and/or the stage of the disease.

    Note: There are no physically invasive tests involved in this evaluation. 

  • Make an Appointment

    (781) 372-7194