Jay W. Marks, MD, is a board-certified internist and gastroenterologist. He graduated from Yale University School of Medicine and trained in internal medicine and gastroenterology at UCLA/Cedars-Sinai Medical Center in Los Angeles.
Melissa Conrad Stöppler, MD, is a U.S. board-certified Anatomic Pathologist with subspecialty training in the fields of Experimental and Molecular Pathology. Dr. Stöppler's educational background includes a BA with Highest Distinction from the University of Virginia and an MD from the University of North Carolina. She completed residency training in Anatomic Pathology at Georgetown University followed by subspecialty fellowship training in molecular diagnostics and experimental pathology.
Due to the broad range and subtleties of symptoms, multiple sclerosis may not be diagnosed for months to years after the onset of symptoms. Physicians, particularly neurologists, take detailed histories and perform complete physical and neurological examinations.
MRI (magnetic resonance imaging) scans with intravenous gadolinium helps to identify, describe, and in some instances date lesions in the brain (plaques).
An electro-physiological test, evoked potentials, examines the impulses traveling through the nerves to determine if the impulses are moving normally or too slowly.
Finally, examining the cerebro-spinal fluid that surrounds the brain and spinal cord may identify abnormal chemicals (antibodies) or cells that suggest the presence of
multiple sclerosis.
Collectively, these three tests help the physician in confirming the diagnosis of
multiple sclerosis. For a definite diagnosis of multiple sclerosis, dissemination in time (at least two separate symptomatic events or changes on MRI
over time) and in anatomical space (at least two separate locations within the central nervous system,
which can be demonstrated by MRI or neurological exam) must be demonstrated.
How is multiple sclerosis treated?
There are many issues for the patient and physician to consider in treating
multiple sclerosis. Goals may include:
improving the speed of recovery from
attacks (treatment with steroid drugs);
reducing the number of attacks or the
number of MRI lesions; or
attempting to slow progression of the disease (treatment with
disease modifying drugs or DMDs).
An additional goal is relief from complications due to the loss of function of affected organs (treatment with drugs aimed at specific symptoms).
Most neurologists will consider treatment with DMDs once the diagnosis of relapsing remitting multiple sclerosis is established. Many will begin treatment at the time of the first multiple sclerosis attack, since clinical trials have suggested that patients in whom treatment is delayed may not benefit as much as patients who are treated early.
It is important for patients to talk to their doctor before deciding to go on therapy since DMDs differ in their uses (for example, one DMD may be used for slowing progressing disability but not for treatment of the first attack of MS; another DMD may be used for reducing relapses but not for slowing progressing disability). Finally, utilizing support groups or counseling may be helpful for patients and their families whose lives may be affected directly by multiple sclerosis.
Once goals have been set, initial therapy may include medications
to manage attacks, symptoms, or both. An understanding of the
potential side effects of drugs is critical for the patient because
sometimes side effects alone deter patients from drug therapy.
Patients may choose to avoid drugs altogether or choose an
alternative drug that may offer relief with fewer side effects. A
continuous dialogue between the patient and physician about the
medications is important in determining the needs for treatment.
Drugs known to affect the immune system have become the primary focus for managing
multiple sclerosis. Initially, corticosteroids, such as prednisone
(Deltasone, Liquid Pred, Deltasone, Orasone, Prednicen-M) or methylprednisolone
(Medrol, Depo-Medrol), were widely used. However, since their effect on the immune system is non-specific
(general) and they may use may cause numerous side effects, corticosteroids now tend to be used to manage only severe
multiple sclerosis attacks (that is, attacks leading to physical disability or
causing pain).
Interferons for relapsing multiple sclerosis
Since 1993, medications that alter the immune system, particularly interferons, have been used to manage multiple sclerosis. Interferons are protein messengers that cells of the immune system manufacture and use to communicate with one another. There are different types of interferons, such as alpha, beta, and gamma. All interferons have the ability to regulate the immune system and play an important role in protecting against intruders including viruses. Each
interferon functions differently, but the functions overlap. The beta interferons have been found useful in managing multiple sclerosis.
Interferon beta-1b (Betaseron®) was the first interferon approved in the U. S. to manage RR-MS in 1993.
In 1996, intramuscular interferon beta-1a (Avonex®) gained FDA approval for RR-MS.
Subcutaneous Interferon beta-1a (Rebif®) was approved in the U. S. in 2002.
The FDA also approved the marketing of Interferon beta-1b under the brand name Extavia® in 2009.
Overall, patients treated with interferons experience fewer relapses or a longer interval between relapses. Avonex® and Rebif® are used to slow progressing disability. The most common side effect is a flu-like syndrome that includes fever, tiredness, weakness, chills, and muscle aches. This syndrome tends to occur less frequently as therapy continues. Other common side effects are injection site reactions, changes in blood cell counts, and
abnormalities of liver tests. Regular liver tests and blood counts are recommended for patients receiving beta-interferons. Periodic thyroid function testing also is recommended because of the effects of beta-interferons on the thyroid gland. With the concomitant use of analgesics and evolving nursing experience with managing local skin reactions, the tolerability to interferons seems to have improved over the years.
Clinical trials of beta-interferon in patients with the first attack of multiple sclerosis showed that in this early patient population, the second attack was delayed. Interferons approved by the FDA for treatment at the first attack of multiple sclerosis include Avonex®, which is administered intramuscularly once a week, and Betaseron® or Extavia®, which are administered subcutaneously every other day.
Available beta-interferons include:
Interferon beta-1b (Betaseron®
and Extavia®) are used for the treatment of relapsing forms of multiple sclerosis, to reduce the frequency of clinical relapses. Patients with multiple sclerosis in whom efficacy has been demonstrated include patients who have experienced a first clinical episode and have MRI features consistent with multiple sclerosis.
Interferon beta-1a (Rebif®) is used for the treatment of patients with relapsing forms of multiple sclerosis to decrease the frequency of clinical relapses and delay the accumulation of physical disability. Efficacy of Rebif® in chronic progressive multiple sclerosis has not been established.
Interferon beta-1a (Avonex®) is used for the treatment of patients with relapsing forms of multiple sclerosis to slow the accumulation of physical disability and decrease the frequency of clinical relapses. Patients with multiple sclerosis in whom efficacy has been demonstrated include patients who have experienced a first clinical episode and have MRI features consistent with multiple sclerosis. Safety and efficacy in patients with progressive multiple sclerosis has not been established.
Muscle spasms are involuntary muscle contractions that come on suddenly and are usually quite painful. Dehydration, doing strenuous exercise in a hot environment, prolonged muscle use, and certain diseases of the nervous system may cause muscle spasms. Symptoms and signs of a muscle spasm include an acute onset of pain and a possible bulge seen or felt beneath the skin where the muscle is located. Gently stretching the muscle usually resolves a muscle spasm.
Itching can be a common problem. Itches can be localized or generalized. There are many causes of itching to include: infection (jock itch, vaginal itch), disease (hyperthyroidism, liver or kidney), reactions to drugs, and skin infestations (pubic or body lice). Treatment for itching varies depending on the cause of the itch.
Impotence, also known as erectile dysfunction, is a common
problem among men characterized by the consistent inability to sustain an
erection sufficient for sexual intercourse or the inability to achieve
ejaculation, or both. Impotence can have emotional causes but most often it is
due to a physical problem.
Overactive bladder is a sudden involuntary contraction of the muscle wall of the bladder causing urinary urgency (an immediate unstoppable need to urinate). Overactive bladder is is a form of urinary incontinence. Treatment options may include Kegel exercises, biofeedback, vaginal weight training, pelvic floor electrical stimulation, behavioral therapy, and medications.
Dysphagia or difficulty in swallowing, swallowing problems. Dysphagia is due to problems in nerve or muscle control. It is common, for example, after a stroke. Dysphagia compromises nutrition and hydration and may lead to aspiration pneumonia and dehydration.
Neuropathic pain is chronic pain resulting from injury to the nervous system. The injury can be to the central nervous system (brain and spinal cord) or the peripheral nervous system (nerves outside the brain and spinal cord).
Hydronephrosis is a condition in which the kidney swells, due to a backup of urine. Hydronephrosis generally occurs with another disease.Symptoms of hydronephrosis include nausea, vomiting, urinary tract infection, fever, painful urination, increased urinary frequency and urgency, flank pain, and swelling of the abdomen. Treatment of hydronephrosis depends on the cause.
Optic neuritis is inflammation of the optic nerve, the structure that connects the eye to the brain. The precise cause of optic neuritis is unknown, but it is thought to be a type of autoimmune disorder. Optic neuritis most commonly develops due to an autoimmune disorder that may be triggered by a viral infection.
There are many types of urinary incontinence (UI), which is the accidental leakage of urine. These types include stress incontinence, urge incontinence, and overflow incontinence. Urinary incontinence in men may be caused by prostate or nerve problems. Treatment depends upon the type and severity of the UI and the patient's lifestyle.
Urinary retention (inability to urinate) may be caused by nerve disease, spinal cord injury, prostate enlargement, infection, surgery, medication, bladder stone, constipation, cystocele, rectocele, or urethral stricture. Symptoms include discomfort and pain. Treatment depends upon the cause of urinary retention.
People who have bladder spasms, the sensation occurs suddenly and often severely. A spasm itself is the sudden, involuntary squeezing of a muscle. A bladder spasm, or "detrusor contraction," occurs when the bladder muscle squeezes suddenly without warning, causing an urgent need to release urine. The spasm can force urine from the bladder, causing leakage. When this happens, the condition is called urge incontinence or overactive bladder.
Millions of women suffer from urinary incontinence (UI). UI occurs twice as often in women as in men. There are many types of urinary incontinence: stress incontinence, urge incontinence, overactive bladder, functional incontinence, overflow incontinence, transient incontinence, and mixed incontinence.
A nerve problem might affect your bladder control if the nerves that are supposed to carry messages between the brain and the bladder do not work properly. Such problems include urine retention, poor control of sphincter muscles, and overactive bladder. Treatment depends upon the cause of the nerve damage and resulting type of bladder control problem.
Double vision (diplopia) is a symptom that my indicate Graves' disease, myasthenia gravis, stroke, multiple sclerosis, Guillain-Barre syndrome, diabetes, cataracts, aneurysm, brain tumor, or migraine. Symptoms and signs include eye pain, droopy eyelids, nausea, headache, and a cross-eyed appearance. Treatment of double vision depends upon the underlying cause.
Vitamin D deficiency has been linked with rickets, cancer, cardiovascular disease, severe asthma in children and cognitive impairment in older adults. Causes include not ingesting enough of the vitamin over time, having limited exposure to sunlight, having dark skin, and obesity. Symptoms include bone pain and muscle weakness. Treatment for vitamin D deficiency involves obtaining more vitamin D through supplements, diet, or exposure to sunlight.
The term alternative therapy, in general, is used to describe any medical treatment or intervention that has not been scientifically documented or identified as safe or effective for a specific condition. Alternative therapy encompasses a variety of disciplines that range from diet and exercise to mental conditioning to lifestyle changes.
Reduction of the sense of smell is termed hyposmia. Total inability to detect odors is termed anosmia. Smell disorders have many causes. Most people who develop a smell disorder have recently experienced an illness or an injury.