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Treatment for Multiple Sclerosis
TREATMENT OF MS
                            Randall Schapiro M.D.

TREATMENT OVERVIEW

The treatment of MS has evolved from an attitude of "go home and rest" to management programs which can be quite extensive. The principle of management is to treat according to the type of MS. MS may be divided into five broad categories according to the course the disease takes: (I) benign, (2) benign exacerbating/remitting (3) chronic relapsing progressive, (4) chronic progressive, and (5) acute progressive.

There is no known specific treatment for the loss of myelin in MS. Cortisone in its various forms (ACTH, Prednisone, Decadron, Medrol) appears to decrease the swelling (inflammation) caused by the immune system's attack of myelin, allowing for speedier resolution of the attack. Speed can be important if significant function is being interrupted. Cortisone, does not appear, however, to make for a better resolution. It also has many side effects including weight gain, brittle bones, salt /water problems, ulcers, cataracts, acne, etc. Thus, the risks versus the benefits must be assessed.

The body's immune system is responsible for fighting foreign substances. An explosion of knowledge in the 1980's has offered a better understanding of how the MS immune system does not perform normally. The immune system is composed of substances made in many areas of the body and normally transported in the blood stream. The immune system effectively talks to itself and regulates its actions. Sometimes it malfunctions and recognizes something foreign which is not. Myelin may very well be the target in the person with MS.

Learning to regulate the immune system will be a major goal of MS research in the '90's. There are some drugs available which sometimes help but have significant side effects. Better drugs are needed. Current immune medicines may include Cytoxan and Imuran, both of which are used in cancer chemotherapy. To alter an immune system, chemicals may be used, or mechanical removal may be tried (lymphocytapheresis) or radiation of the immune structures (total lymphoid irradiation) may be given. Research is being done with all of these. The final chapter is yet to be written in this area.

Over the years, diets have been used to treat multiple sclerosis. More diets are available at this time than at any other time in history, including diets low in polyunsaturated fats; low in gluten; high in vitamins, especially B, E, and C; high in lecithin and linoleic acid; as well as diets that assume that each individual is allergic to certain types of food. Once again, some research findings substantiate each and every diet, but the vast majority of research indicates that no diet is a certain treatment for multiple sclerosis. Good nutrition is important for everyone. Thus, a good, nutritionally sound diet is important for better health but it likely will not alter MS itself.

The therapies already discussed deal with multiple sclerosis directly and, for the most part, unsuccessfully. Despite this, great strides have been made treating the symptoms of multiple sclerosis. While treating symptoms does not eliminate the disease itself, it can make the life of multiple sclerosis patients far more comfortable, especially when stiffness or spasticity are involved. Over the last few years, many anti-spastic drugs have been introduced and are now being used by doctors treating multiple sclerosis.

Diazepam (Valium) was one of the first. This drug tends to sedate people and can be habit-forming, but it does reduce spasticity. Dantrolene sodium (Dantrium) was introduced initially for spasticity in stroke and cerebral palsy patients. When tried in multiple sclerosis, it brought about a general weakness which was extremely uncomfortable. Nonetheless, some patients tolerate this medication well and receive considerable relief from stiffness.
Baclofen (Lioresal) appears to reduce spasticity in multiple sclerosis patients without causing them to become unduly weak. Some patients on baclofen have problems with weakness and sleepiness but for the most part this medication has been quite successful in the management of spasticity. For patients who are severely stiff, introducing baclofen directly into the spinal canal appears to have some benefit. This is done through an implanted pump. While this is costly and aggressive, it has been successful in reducing severe stiffness. Stiffness can be altered mechanically by blocking the junction where the nerve and muscle meet. This is called a "motor point block." The disadvantage of motor point block is that tissue is destroyed. In a disease with potential reversibility, destroying tissue is looked upon with disfavor.
Besides helping multiple sclerosis patients with stiffness, doctors can now help more with bladder problems like frequency, urgency, dribbling and the occasional hesitancy of urination. Bladders of multiple sclerosis patients are quite varied and complex. They may be very large and unresponsive, allowing over-filling. On the other hand, bladders may be very small and hyperactive, causing the very same symptoms. Usually doctors need to perform some diagnostic studies to determine which type of bladder is present before selecting the drugs to treat it.
Urecholine has been a popular drug for patients who have a large unresponsive type of bladder. Probanthine, Banthine, Urispas and Ditropan have been popular drugs for patients who have small, hyperactive bladders. In patients who have a fairly substantial amount of urine remaining in their bladder, a technique called self-intermittent catheterization can successfully remove the excess urine. This involves inserting a tube into the bladder intermittently to relieve it of excess urine. But patients must have reasonably good dexterity in their hands to accomplish this easily. Urinary infection also leads to increased bladder irritability and symptoms. Drugs that reduce infections (like Septra, vitamin C, Mandelamine, Macrodantin and others) are often used to keep the bladder from becoming infected.

While rare with multiple sclerosis, occasionally patients experience pain. Routine pain medications appear to have very little effect, but anti-seizure drugs like Tegretol and Dilantin appear to help multiple sclerosis-type pain. These drugs operate by a different mechanism than routine pain killers. Sometimes major tranquilizers such as Taractan can successfully treat multiple sclerosis pain. At times, transcutaneous nerve stimulation (in effect, a "local pacemaker"), can calm the painful area and make the pain far more tolerable.

Treating tremor in multiple sclerosis is one of the more frustrating clinical problems. In one variety of multiple sclerosis, the patient may have good strength but much tremor, making it impossible for that strength to be used. No drugs can treat tremor adequately in multiple sclerosis. Yet occasionally, relaxing drugs such as Valium, Haldol, Thorazine, and Atarax will allow limited success. Propranolol (Inderal) has a different mechanism of action and can occasionally tone down gross tremor.

Most patients who have multiple sclerosis do quite well and need to be checked only periodically. Occasionally, a hospitalization for an exacerbation is needed. Sometimes allied health professionals have much to contribute to the care of the MS patient. Help from the occupational therapist, the physical therapist, the social worker, the nurse, the vocational rehabilitation counselor, the psychologist and other qualified allied health workers is essential.

Because MS affects young people, because it can be severe and because there is no firm understanding of the etiology and treatment of the disease, many new and untried medical treatments appear from time to time. Most of these are not based on any rational scientific explanation and, over the years, have proven to be of no benefit. However, many people are sitting on the edges of their chairs waiting for a miraculous cure to be discovered. This means that a large number of people are susceptible to sometimes dangerous forms of quakery-type medicine. When an MS patient reads about a new form of treatment, it is important for the patient to check that treatment with his or her neurologist before hopes are raised.

While no cure or treatment that is specific for the disease is available at the present time, there is no need to be depressed by what is available. Patients who have multiple sclerosis are numerous. Under proper medical supervision, they continue to lead fairly normal