Multiple Sclerosis 

Multiple Sclerosis 

Multiple sclerosis (MS) is thought to affect more than 2.3 million people worldwide. While the disease is not contagious or directly inherited, epidemiologists have identified factors in the distribution of MS around the world that may eventually help determine what causes the disease (nationalmssociety.org, 2018). It is a chronic, progressive, degenerative neurological disease, associated with immune system deregulation, culminating in demyelination and axonal damage within the central nervous system and is one of the most common neurological diseases in young adults and the leading cause of non‐traumatic disability in young and middle‐aged adults (Gold & Wolinsky, 2010).

Pathophysiology of Multiple Sclerosis

MS is a chronic, heterogeneous and complex disease. Autoreactive T‐cells in the periphery are activated by unidentified mechanism, possibly involving molecular mimicry or bystander activation. Activation of these T cells gives them the potential to migrate across the blood–brain barrier (BBB) via an interaction of integrins on the T‐cell surface with adhesion molecules on the endothelium of the BBB, followed by the degradation of the BBB via the secretion of matrix metalloproteases. Once in the central nervous system (CNS), T cells are reactivated on encountering local CNS antigens via an interaction with antigen‐presenting cells such as macrophages or microglia, or B cells. T cells secrete proinflammatory cytokines, and plasma cells secrete antibodies against myelin, leading to the destruction of the myelin sheath. Ongoing inflammation in the CNS promotes the recruitment of additional inflammatory cells. Activated microglia release free radicals, nitric oxide and proteases, which further contribute to tissue damage and axonal loss (Gold & Wolinsky, 2010).

Prescribed Medications to Modify Progression

Beta interferons: these medications are among the most commonly prescribed medications to treat MS. They are injected under the skin or into muscle and can reduce the frequency and severity of relapses.

Ocrelizumab (Ocrevus): humanized immunoglobulin antibody medication which is the only DMT approved by the FDA to treat both the relapse-remitting and primary progressive forms of MS. Clinical trials showed it reduced relapse rate in relapsing disease and slowed worsening of disability in both forms of the disease.

Glatiramer acetate (Copaxone): helps block the immune system’s attack on myelin and must be injected beneath the skin. 

Dimethyl fumarate (Tecfidera): reduces relapses. Side effects may include flushing, diarrhea, nausea and lowered white blood cell count.

Fingolimod (Gilenya):  reduces relapses. 

Teriflunomide (Aubagio):reduces relapses.

Natalizumab (Tysabri): designed to block the movement of potentially damaging immune cells from your bloodstream to your brain and spinal cord. It may be considered a first line treatment for some people with severe MS or as a second line treatment in others. 

Alemtuzumab (Lemtrada):reduce relapses of MS by targeting a protein on the surface of immune cells and depleting white blood cells. This effect can limit potential nerve damage caused by the white blood cells, but it also increases the risk of infections and autoimmune disorders.

Mitoxantrone: immunosuppressant drug can be harmful to the heart and is associated with development of blood cancers. As a result, its use in treating MS is extremely limited, therefore, is usually used only to treat severe, advanced MS.

Treatments for MS Attacks

Corticosteroids (oral prednisone and intravenous methylprednisolone: reduce nerve inflammation. Side effects may include insomnia, increased blood pressure, mood swings and fluid retention.

Plasma exchange (plasmapheresis). The liquid portion of part of your blood (plasma) is removed and separated from your blood cells. The blood cells are then mixed with a protein solution (albumin) and put back into your body. Plasma exchange may be used if your symptoms are new, severe and haven’t responded to steroids.

Controlling Negative Side Effects of Corticosteroids

Insomnia: evaluate if total dose can be taken in the morning. Establish a regular hour for getting into bed and small rituals that help you prepare for sleep. Make sure the bedroom is cool and dark and free of noise. 

Mood Changes: with doses over 30 milligrams per day, steroids can affect your moods. Some people can feel depressed, some extremely “up” and others go up and down for no apparent reason.  Medications can be taken to help with these mood changes.

Fluid Retention and Elevated Blood Pressure: because cortisone is involved in regulating the body’s balance of water, sodium, and other electrolytes, using these drugs can promote fluid retention and sometimes cause or worsen high blood pressure. It is important to maintain a low sodium diet to reduce fluid accumulation in turn controlling blood pressure. If hypertension persists, diuretics may be prescribed (Fields, 2017). 

MS and Genetics

Genetic factors are thought to play a significant role in determining who develops MS.For first-degree relatives of a person with MS, such as children, siblings or non-identical twins, the risk rises to approximately 2.5-5% — with the risk being potentially higher in families that have several family members with the disease.The identical twin of someone with MS (who shares all the same genes) has a 25% chance of developing the disease. If genes were solely responsible for determining who gets MS, an identical twin of someone with MS would have a 100% chance of developing the disease; the fact that the risk is only one in four demonstrates that other factors, including geography, ethnicity and the elusive infectious trigger, are likely involved as well.Research has demonstrated that MS occurs in most ethnic groups, including African-Americans, Asians and Hispanics/Latinos, but is most common amongst Caucasians of northern European ancestry. Susceptibility rates vary among these groups, with recent findings suggesting that African-American women have a higher than previously reported risk of developing MS (nationalmssociety.org, 2018).

 

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