MS, Part 2: New Treatments Improve Quality of Life

Multiple sclerosis (MS) was first diagnosed in 1849, according to the National Institute of Neurological Disorders and Stroke (NINDS), but a century and a half later, it remains a baffling condition whose cause is still unknown, and a disease for which there is still no cure or vaccine. Nevertheless, the outlook for MS patients is much more promising today than it was just a decade ago.

The National Institutes of Health notes that since 1989, when Congress declared the 1990s the "Decade of the Brain," there has been "an unparalleled explosion of knowledge about neurological disorders. New technologies are forcing even complex diseases like MS to yield up their secrets." Although factors such as genetics, viral infections, climate and environment are studied for their role in MS, many research scientists today - including those at The Medical College of Wisconsin - view MS as an autoimmune disease, one in which the patient's body attacks its own tissue. In this case, the tissue targeted is the myelin, which insulates nerves.

"Right now, all our treatments are immunomodulators, and most of them have been introduced in the past 10 years," says Cheryl Blaschuk, RN, MSN, FNP, a Nurse Practitioner who sees patients at the Froedtert & The Medical College Multiple Sclerosis Clinic, part of the Froedtert & The Medical College of Wisconsin Neuroscience Center. Immunomodulators are a class of drugs that influence the body's immune system.

Protecting the Nervous System
"Today, the goal of treatment is to decrease the inflammatory process, thereby decreasing the number and severity of relapses in the hope of slowing further disability," says Blaschuk, who is board certified by the International Organization of Multiple Sclerosis Nurses. "We're looking at ways to protect the nervous system and make the progression slower between relapses. The new drugs seem to help that happen."

These immunomodulators contain naturally occurring antiviral proteins known as interferons. According to NINDS, the Food and Drug Administration (FDA) has now approved three forms of beta interferon for treatment of relapsing-remitting MS. "Beta interferon has been shown to reduce the number of exacerbations and may slow the progression of physical disability. When attacks do occur, they tend to be shorter and less severe. In addition, MRI scans suggest that beta interferon can decrease destruction of the myelin."

At the Froedtert & The Medical College MS Clinic, Blaschuk - who works with Lea H. Rayman, MD, an Assistant Professor of Neurology and an MS specialist - teaches patients how to administer the three beta interferon drugs:

• Avonex - Injected intramuscularly once a week
• Betaseron - Injected under the skin every other day
• Rebif - Injected under the skin three times a week

A fourth drug, Copaxone, has a different action from the interferon drugs. The manufacturer says researchers believe that Copaxone changes the way the immune system reacts to MS by preventing harmful cells from developing and by stimulating beneficial cells that help reduce inflammation at the sites of the lesions. It is injected daily under the skin.

Another newer MS drug, Tysabri (also called natalizumab), was withdrawn from the market by the FDA in February 2005, only three months after it was approved, when three patients out of 3,000 in a clinical trial developed a rare brain disease after taking the drug. In March 2006, however, an FDA panel voted to reinstate the drug to carefully screened patients who are entered in a registry. They and their doctors would be required to sign forms acknowledging the risk.

Steroids Now Used Sparingly
Before the newer therapies were developed, the most common MS treatment were intravenous steroid infusions, Blaschuk says. "Today we might use IV steroids followed by a short course of oral prednisone to decrease inflammation in patients experiencing a relapse of symptoms or a new symptom that persists for 24 hours or more. We no longer prescribe oral steroids for extended periods." Steroids, if used for long periods, can increase the risk of osteoporosis, stomach ulcers and a rare destruction of a bone due to the lack of blood supply (avascular necrosis).

In addition to the drug therapies, patients at the Froedtert & The Medical College MS Clinic undergo regular MRI scans, which Blaschuk says are crucial to diagnosing and managing their disease. Clinic patients also have access to a multidisciplinary team of specialists - neurologists, urologists, physiatrists (physicians specializing in physical medicine and rehabilitation), and physical and occupational therapists. By summer 2006, more physicians whose patient focus is MS will join the faculty, she says.

Meanwhile, researchers continue probing for clues to the cause of MS. "We suspect environmental factors with genetic factors," says Blaschuk, "although we don't know which specific gene is involved. And although MS is an autoimmune disorder, we don't know the exact mechanism or action. There is an inflammatory component, but there is also a degeneration of the nerve cells themselves that occurs early in the disease, even if the patient does not show signs of disability.

"It is the loss of the nerve cells (axonal degeneration) that leads to the permanent disability patients experience. This may take many years to occur, but we now know that it happens early in the disease. For this reason we advocate treating this disease early even if patients do not seem to have any major physical problems."

If researchers still don't know what causes MS, they have ruled out a number of factors that have widely been believed to be involved. "Diet soda does not cause MS," Blaschuk says. "We still get asked about that. Neither do fillings in your teeth, but some patients believe they do and want their fillings taken out."

Certain foods are sometimes suspected as triggering MS, but none has been proven, according to NINDS, which says: "Some physicians have advocated a diet low in saturated fats; others have suggested increasing the intake of linoleic acid, a polyunsaturated fat, via supplements of sunflower seed, safflower or evening primrose oils. Other proposed dietary "remedies" include megavitamin therapy, including increased intake of vitamins B12 or C; various liquid diets; and sucrose-, tobacco- or gluten-free diets. To date, clinical studies have not been able to confirm benefits from dietary changes. In the absence of any evidence that diet therapy is effective, patients are best advised to eat a balanced, wholesome diet."

Blaschuk, who also advocates physical activity for MS patients, concurs with NINDS: "This is a disease that will be harder to manage if you don't take care of yourself, and that includes eating a healthy diet.

"Until we figure out a cause," Blaschuk says, "we continue looking at ways to protect the nervous system and slow the progression of the disease. Today we start treatments early, and we're seeing better outcomes. A few years ago, MS wasn't treated until symptoms became severe.

"The take-home message," she says, "is to seek diagnosis and treatment early, even if you seem to feel better. Right now, you cannot reverse MS or 'fix' it, but you can improve your quality of life."

Barbara Abel
HealthLink Contributing Writer

See the April 15, 2006 issue of HealthLink to read the first section of this two-part article: MS, Part 1: Diagnose Difficult, Cause Unknown.

MCW Health News presents up-to-date information on patient care and medical research by the physicians of the Medical College of Wisconsin.