Is there treatment available?

Yes there are a lot of options in terms of treatment for patients with multiple sclerosis.

• The treatments are divided into
• Acute treatment of a relapse
• Disease modifying treatment
• Treatment of symptoms

Acute treatment of a relapse

If you have presented with what appears to be a relapse of multiple sclerosis (either first time presenting or with a history of multiple sclerosis) you are likely to receive a course of steroids. These will most frequently be given intravenously but can be given orally if necessary. It is a standard dose given for 3 or 5 days. The idea is to hasten the recovery from the relapse. This treatment does not, however, have any effect on the disease course. When you are given intravenous steroids you will be given a medication also to prevent stomach ulcers as steroids can cause these. Because it is such a short course of steroids you will not be at risk of any of the long-term consequences of steroid treatment such as osteoporosis or diabetes.

The steroids will help hasten recovery from a relapse. However during the relapse if there are symptoms such as pain this may be treated with nerve pain killers (the same ones used in the treatment of painful neuropathy). If your mobility has been affected as part of your relapse then a course of physiotherapy may be useful also.

Disease modifying treatment

There are several options available for disease modifying treatment. Whichever one you get treated with will depend on the level of severity of your multiple sclerosis and the risks involved in the treatment.

The potential beneficial effects are both a reduced rate of attacks and a slower accumulation of brain lesions on the MRI scan.

The treatments come either as an injection (under the skin or in to muscle), oral medication or intravenous infusions. Most of the treatments listed below are continued indefinitely unless there are intolerable side effects. If there are continuing attacks on a particular treatment, a change to another one may be necessary and this is something that your neurologist will decide with you.

• Below are the disease modifying medications that are available:
• Betaferons - These are the commonest treatment for multiple sclerosis. They are given by means of an injection either under the skin on alternate days or in to muscle once a week. Betaferons have been shown to reduce the frequency and severity of attacks. These can cause mild flu like symptoms around the time of the injection but this can be managed by pre-treatment with paracetomol. The liver function and white cell count need to be checked while on this treatment. There is a small proportion of patients who develop “neutralising” antibodies and this can reduce the effectiveness of the medication. If there is any suspicion that you may have developed these your neurologist will check with a blood test. If you have you may need a change of treatment. This medication can cause skin irritation also when injected under the skin. This is usually managed by rotating the sites of injection. If you are put on this treatment a nurse usually calls to you to show you how to inject yourself.
• Glatiramer acetate (copaxone) - This is also a commonly used treatment for multiple sclerosis. It is also given by injection under the skin. It may help block your immune systems attack on the myelin. It can cause some irritation also at the site of injection.
• Fingolimod (gilenya) - This is an oral medication for the treatment of multiple sclerosis. It has been shown to reduce the frequency of attacks. It is taken once daily. Before being given this medication you will have to make sure you have immunity against varicella zoster (the shingles virus) as this medication can cause reactivation of this virus. It can cause slowing of the heart rate temporarily and for this reason the first dose is always given in hospital with supervision and heart monitoring. For this reason, patients with prior history of heart attacks or other heart problems should not receive this medication without this being checked by a cardiologist. Other side effects include headaches, high blood pressure, skin lesions and blurred vision. If you develop skin lesions you will need a dermatologist to assess them. Similarly, if you develop blurred vision then you will need to have your eyes checked. Liver function should be checked also before starting this medication and for a number of months after.
• Dimethyl fumarate (tecfidera) - This is a twice daily oral medication for multiple sclerosis. It has been shown to reduce the frequency of relapses. Side effects of this medication include flushing, diarrhoea and nausea. It can cause a reduction also in the white cell count and can have an effect on liver function and therefore blood tests need to be done before giving the medication and then every month after for a few months.
• Teriflunomide (ambagio) - This is also a once daily medication that has been shown to reduce the attack rate. It can cause liver damage and hair loss. Therefore, liver function must be tested before starting this medication and then every month for a few months after starting it. Of great importance is that it is harmful to a developing foetus and should not be used by women who are or may become pregnant or are not using adequate contraception. This also applies to men who are using the drug in terms of causing harm to the foetus.
• Natalizumab (tysabri) - This medication is given as a once monthly infusion. It acts by blocking the transfer of potentially damaging immune cells from your blood stream to your brain and spinal cord. This may be considered as the first treatment to use for patients with severe disease. There is an increased risk of a brain infection called “progressive multifocal leukoencephalopathy” on this medication. However, your risk of this really depends on whether or not you have been exposed to this particular virus in your lifetime. This can be established before starting treatment on it. There can be some infusion related reactions- such as headache, flushing, nausea and dizziness. Side effects can also include fatigue, allergic reactions, and infections.
• Alemtuzumab (Lemtrada) - This medication also helps reduce the frequency of attacks and is reserved for more aggressive forms of multiple sclerosis. It acts by depleting white blood cells which helps reduce the immune attack. The treatment involves 5 days of intravenous infusions followed by 3 days one year later. There can be infusion related reactions as described above for natalizumab. After receiving this treatment your bloods will be checked every month mainly to look at the number of platelets (as it can cause a reduction in this) and thyroid function.
• Mitoxantrone - This is a medication that is really used only when there has been no response to the other immune treatments. This is because it can have a toxic effect on the heart. Therefore, the use of this medication is highly specialised and will not be discussed further here.

Treatment of symptoms:

Fatigue - This is quite a common symptom of multiple sclerosis and is unfortunately quite difficult to treat. It is usually described as physical exhaustion that is unrelated to physical activity. The first thing to do in managing this symptom is to make sure all potential contributors such as pain or poor sleep are dealt with. Depression can be a contributor to fatigue also so should always be considered. Some of the medications used to treat pain can cause fatigue as a side-effect. Increasing the level of physical activity can help with fatigue. There are medication options if the fatigue is still occurring despite considering all the potential contributors and increasing the physical activity. These are amphetamine based medications that should be taken in the morning time. These include modafanil and methylphenidate amongst others. They are usually used for other conditions that cause fatigue but some patients with multiple sclerosis find them beneficial. They should be taken in the morning as they can interfere with sleep if taken too late in the day. Sometimes treating with anti-depressant medications that fall under the SSRI (selective serotonin reuptake inhibitors) category of medications have been shown to have a crossover effect and treat both depression and fatigue.

Muscle stiffness - this particular symptom can lead to pain and difficulty with mobilising. This can significantly increase the burden of the illness. This can be managed with medications but non-medication options would include physiotherapy and a daily stretching program. The medications work by reducing spasms in the muscles and thereby reduce stiffness. These medications need to be prescribed carefully and in very low doses. This is because they are designed to reduce stiffness in muscles and therefore improve function. However if the dose is too high it may reduce the stiffness to the point that the muscles become weak. Another means of treating very stiff or tight muscles is with botox injections right in to the muscles that are causing the main symptoms.

Pain - This is also a common symptom. If the pain is burning in nature or sharp and stinging as you might expect with nerve pain then the medications used are the same as those described in the neuropathy section- treatment of pain.

Poor mobility - There are several contributing factors to poor mobility in multiple sclerosis. This can include pain and stiffness and they can be treated as detailed above. However, an assessment with a physiotherapist would also be very useful. This assessment can help evaluate how you walk and whether or not you are at risk of falling. It is also useful because at some point mobility aids may be necessary such as orthotics for the feet or walking sticks depending on the level of disability. Falls should be avoided as they can lead to further problems such as fractures or muscular injury both of which can negatively impact mobility.

Cognitive issues - The cognitive issues as detailed above can lead to impaired ability to interact with the world as you normally would. Obviously, this can be a source of quite significant stress. The first thing would be to establish other symptoms that may be contributing to poor cognitive function. This would include abnormal sleep patterns, pain levels, fatigue and mood. All of these can negatively impact cognition and so should be identified and treated. If all of these factors are identified and treated and there is still an issue with cognition then development of coping strategies may help. For example, using a personal organiser to remind you of appointments, directions etc. Keeping a phone log may be useful and written reminders of day-to-day things all serve a purpose. Support from family and friends can help also. The medication that is used to treat dementia has not been shown to be effective in cognitive issues created by multiple sclerosis.

Bladder dysfunction - In multiple sclerosis bladder dysfunction can be either failure of the bladder to store urine or failure of the bladder to empty urine. When the problem is failure to store urine the symptom can be frequency of urination and even incontinence. The medication used to treat this is called oxybutynin. It works by reducing the emptying of the bladder and in turn reducing the frequency of needing to urinate. Sometimes this can lead to urine being left in the bladder which will become a source of infection. This can be managed easily by self-catheterising. This is where you would be shown how to insert a tube in to the bladder to empty it- it may sound daunting but once shown how it is actually quite straightforward. The other problem is failure of the bladder to empty urine. The main issue here is that when you empty your bladder there is some urine left behind and this can lead to infection. A medication called tamsulosin can actually help with the bladder emptying function. Again, if this is insufficient in terms of emptying the bladder fully the self-catheterisation mentioned above can be useful.

Bowel dysfunction - In multiple sclerosis the bowel issue can be either constipation or incontinence of stool. When the issue is constipation the first thing to do is look at the diet. Increasing the amount of dietary fibre and hydration can help. Also, physical inactivity or the side effects of medications used to treat something else such as pain or stiff muscles can contribute to constipation. If dietary changes and increasing physical activity do not help then laxatives can be of use. There are several kinds- ones that stimulate the bowel and others that add bulk and help the bowels move through doing this. Whichever is more suitable will really depend on the patient and your neurologist or GP can help with this. Incontinence of stool can be more challenging to manage. However, there are certain things that may help- try and avoid foods or activities that tend to cause the symptom. Supplementing the diet with a bulking agent- such as methylcellulose- can improve stool consistency as well as the use of anti-diarrhoeal agents.

Sleep - Patients with multiple sclerosis can have difficulty with sleep. This can be pure insomnia- as in difficulty with falling asleep. Other causes of trouble with sleeping includes restless legs syndrome which is the sensation or urge to move the legs when lying or sitting down. Pain and stiffness in the muscles can interfere also with sleep as can needing to get up at night to urinate. Addressing all of these issues is the first step to treating difficulty with sleep. Poor sleep can have a negative impact on all the other symptoms of multiple sclerosis such as pain, fatigue and cognitive issues.

Depression - Depression is common in multiple sclerosis. Treatment with both medication and psychotherapy can be beneficial. The choice of treatment will depend upon the side effect profile of the medication and also the other symptoms of multiple sclerosis. For example, if pain and depression are both issues the choice of medication would be one called duloxetine- this has an effect on both mood and pain. For patients who suffer from fatigue and depression a medication called fluoxetine is thought to help with both. If bladder dysfunction is an issue a medication called imipramine can help treat both the mood and may also help with bladder issues. All of these issues can be discussed with your neurologist. But be sure to let your doctor know of all of your symptoms so the most appropriate choice of medication can be made. Non-medication ways of managing depression and low mood include psychotherapy, aerobic exercise, resistance training and aquatic therapy. There are many ways of improving your level of physical activity even if you don’t usually exercise. There are lots of different ways of introducing small amounts of exercise in to your daily schedule.

Speech and swallow dysfunction - Speech and swallow dysfunction are uncommon in multiple sclerosis and really only occur in advanced disease. If there are issues with this then a full assessment with a speech therapist may be of value. The most important thing is to prevent chest infections from an abnormal swallow function.

When you visit your neurologist for a check-up it is important to bring up all the symptoms you may be suffering from as there are many ways of managing them but only if they are identified.

• Checklist of things to talk about with your neurologist:
• Any symptom worsening that may signal a relapse
• Any side effects from medications
• Any blood tests that may be necessary
• Any visual symptoms
• Any pain symptoms
• Any falls or near falls
• Any trouble with the bowel or bladder
• Any sleeping issues
• Any mood problems
• Any speech or swallow trouble