Management of multiple sclerosis – Wikipedia, the free encyclopedia

Several therapies for multiple sclerosis (MS) exist, although there is no known cure. Multiple sclerosis is a chronic inflammatory demyelinating disease that affects the central nervous system (CNS).

The most common initial course of the disease is the relapsing-remitting subtype, which is characterized by unpredictable attacks (relapses) followed by periods of relative remission with no new signs of disease activity. After some years, many of the people who have this subtype begin to experience neurologic decline without acute relapses. When this happens it is called secondary progressive multiple sclerosis. Other, less common, courses of the disease are the primary progressive (decline from the beginning without attacks) and the progressive-relapsing (steady neurologic decline and superimposed attacks). Different therapies are used for patients experiencing acute attacks, for patients who have the relapsing-remitting subtype, for patients who have the progressive subtypes, for patients without a diagnosis of MS who have a demyelinating event, and for managing the various consequences of MS.

The primary aims of therapy are returning function after an attack, preventing new attacks, and preventing disability. As with any medical treatment, medications used in the management of MS may have several adverse effects, and many possible therapies are still under investigation. At the same time different alternative treatments are pursued by many patients, despite the paucity of supporting, comparable, replicated scientific study.

This article focuses on therapies for standard MS; borderline forms of MS have particular treatments that are excluded.

Administration of high doses of intravenous corticosteroids, such as methylprednisolone, is the routine therapy for acute relapses. This is administered over a period of three to five days, and has a well-established efficacy in promoting a faster recovery from disability after an attack.[1][2] There is however insufficient evidence to indicate any significant impact on long-term disability of corticosteroid treatments.[3] Steroids administered orally have a similar effectiveness and safety profile at treating MS symptoms as intravenous treatment.[4] Consequences of severe attacks which do not respond to corticosteroids might be treated by plasmapheresis.[5][6]

As of April 2013, eight disease-modifying treatments have been approved by regulatory agencies of different countries, including the U.S. Food and Drug Administration (FDA), the European Medicines Agency (EMEA) and the Japanese PMDA.

The approved drugs with their trademarks are interferon beta-1a (Avonex, Rebif, CinnoVex, ReciGen), interferon beta-1b (Betaseron), glatiramer acetate (Copaxone), mitoxantrone (Novantrone), natalizumab (Tysabri), fingolimod (Gilenya), teriflunomide (Aubagio)[5][7][8] and dimethyl fumarate (BG12, Tecfidera).[9][10]

In 1993 interferon beta-1b was the first drug to ever be approved for MS, being soon followed by interferon beta-1a and glatiramer acetate.[11] Interferon beta-1a is injected either weekly (intramuscular injection) or three times a week (subcutaneous injection) depending on commercial formulations,[12][13] while interferon beta-1b is injected subcutaneously every second day.[14]Interferon beta balances the expression of pro- and anti-inflammatory agents in the brain, and reduces the number of inflammatory cells that cross the blood brain barrier.[15] Overall, therapy with interferon beta leads to a reduction of neuron inflammation.[15] Moreover, it is also thought to increase the production of nerve growth factor and consequently improve neuronal survival.[15]

Glatiramer acetate is a mixture of random polymers of four amino acids which is antigenically similar to the myelin basic protein, a component of the myelin sheath of nerves with which it competes for presentation to T cells . It is injected subcutaneously on a daily basis.[16][17][18]

Mitoxantrone is an immunosuppressant also used in cancer chemotherapy which was approved for MS in the year 2000;[19] whereas natalizumab is a monoclonal antibody that was initially approved in 2004.[20] Both are given by intravenous infusion at monthly intervals in the case of natalizumab and every three months in the case of mitoxantrone.[19][21][20]

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Management of multiple sclerosis - Wikipedia, the free encyclopedia