Treatment

The treatment of patients with MS includes

• Acute treatment of exacerbations
• Preventive treatment of relapses
• Symptomatic treatment
• Neuro Psychological Assessment

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 prednisone tapering may follow its administration. Possible side effects include

• 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 person. 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.

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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. In cases of continued breakthrough disease despite the use of these drugs, the addition of an oral or IV immunosuppressive agent is often necessary.

Immunomodulators

There are two major types of immunomodulator agents; they are outlined below:

Interferon Beta

Side effects of these medications may include flu-like symptoms and depression. Subtypes of interferon beta medications include 1a and 1b.

• 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

Glatiramer Acetate (Copaxone)

Side effects of these medications 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.

Monoclonal Antibodies

Monoclonal 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 and is usually well tolerated.

Tysabri is currently approved only as a monotherapy, because of the occurrence of two cases of progressive multifocal leukoencephalopathy (a rare brain infection caused by the JC virus) in patients treated with a combination of Tysabri and Avonex.

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.

Immunosuppressors

Common immunosuppressive agents used include

Intravenous: Mitoxantrone (Novantrone) Cyclophosphamide (Cytoxan)

Oral: Azathioprine (Imuran) Methotrexate (Folex, Rheumatrex) Mycophenolate mofetil (CellCept)

Possible 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.

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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)

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.

Pain

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

• 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 choices exist for the treatment of depression, including:

Selective serotonin reuptake inhibitors (SSRIs)

• Fluoxetine (Prozac)
• Sertraline (Zoloft)
• Paroxetine (Paxil)
• Citalopram (Celexa)
• Escitalopram oxalate (Lexapro)

Atypical antidepressants

• Venlafaxine (Effexor)
• Bupropion (Wellbutrin)

Neurogenic bladder

Urinary symptoms are present in more than half of all MS patients. 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. Treatments include:

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.

Neuro Psychological Assessment

Many patients who are being seen in the MS Clinic are also being referred for a neuropsychological evaluation. The purpose of a neuropsychological evaluation is to evaluate 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 will be no physically invasive tests involved in this evaluation.

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