What is the management for multiple sclerosis (MS)?

Management of Multiple Sclerosis

Autologous haematopoietic stem cell transplantation (AHSCT) is recommended for relapsing forms of multiple sclerosis that are refractory to disease-modifying therapy, particularly in aggressive forms of relapsing-remitting MS. 1

Disease-Modifying Therapies

First-Line Treatment Options

• Relapsing forms of MS (including clinically isolated syndrome, relapsing-remitting disease, and active secondary progressive disease):
  • Injectable therapies: Interferon beta, glatiramer acetate
  • Oral therapies: Dimethyl fumarate, teriflunomide, fingolimod
  • Monoclonal antibodies: Natalizumab (indicated as monotherapy) 2

Treatment Algorithm

1. Initial presentation/early disease:

   • Start with first-line agents based on disease activity, safety profile, and patient preferences
   • Monitor with MRI and clinical assessments for disease activity

2. Breakthrough disease:

   • Switch to higher efficacy agents (natalizumab, ocrelizumab, alemtuzumab)
   • Consider AHSCT for aggressive disease refractory to high-efficacy DMTs 1

3. Progressive MS:

   • Limited options - ocrelizumab for primary progressive MS
   • AHSCT benefits less clear in primary progressive MS 1

Symptom Management

A comprehensive approach to symptom management is essential for quality of life 3:

Mobility and Physical Symptoms

• Spasticity: Baclofen, tizanidine, gabapentin, physical therapy
• Fatigue: Energy conservation techniques, amantadine, modafinil
• Balance/Gait: Physical therapy, assistive devices, dalfampridine

Autonomic Dysfunction

• Bladder dysfunction: Anticholinergics, intermittent catheterization
• Bowel dysfunction: Dietary modifications, laxatives, suppositories
• Sexual dysfunction: Phosphodiesterase-5 inhibitors, lubricants, counseling

Neuropsychiatric Symptoms

• Cognitive dysfunction: Cognitive rehabilitation, acetylcholinesterase inhibitors
• Depression: SSRIs, psychotherapy
• Pain: Gabapentin, pregabalin, tricyclic antidepressants, carbamazepine

Diagnostic Monitoring

MRI Monitoring

• T2-weighted spin echo sequences are more sensitive for demonstrating MS lesions 1
• Gadolinium enhancement should be used to identify active inflammatory lesions 1
• Standardized protocols:
  • 5 mm slice thickness with minimal interslice gap
  • 256 x 256 matrix
  • Scanning should start at least five minutes after gadolinium injection 1

CSF Analysis

• Recommended in patients with suspected MS where clinical and MRI findings are insufficient for diagnosis
• Useful for cases with atypical presentations or possible alternative diagnoses
• Not used for monitoring disease progression or treatment response 4
• Key biomarkers:
  • Oligoclonal bands
  • Neurofilament light chain (NfL) - marker of axonal damage
  • Glial fibrillary acidic protein (GFAP) - associated with progressive disease 4

Advanced Treatment Options

AHSCT Considerations

• Most effective in relapsing-remitting MS and early secondary progressive MS
• Highly effective at stopping inflammation in the brain
• Can stabilize or improve function in relapsing-remitting MS
• Benefits less clear in primary progressive MS
• Higher acute risk than many DMTs - careful patient selection required 1

AHSCT Indications

1. Aggressive forms of relapsing-remitting MS after failure of high-efficacy DMTs
2. Rapidly evolving, severe, treatment-naive MS (case-by-case basis)
3. Not routinely recommended for primary progressive MS 1

Multidisciplinary Care Approach

The MS Care Unit model provides comprehensive care and typically includes 5:

• MS neurologists and specialized nurses
• Neuropsychologists and clinical psychologists
• Physiotherapists and occupational therapists
• Coordination with other specialists (urologists, ophthalmologists, etc.)

Lifestyle and Complementary Approaches

Evidence supports the following interventions 6:

• Physical activity and exercise programs
• Smoking cessation
• Vitamin D supplementation
• Mindfulness practices
• Polyunsaturated fatty acid supplementation

Treatment Pitfalls to Avoid

• Delaying treatment initiation in active disease
• Inadequate monitoring of treatment response
• Overlooking symptom management while focusing only on disease modification
• Failing to address psychological aspects of the disease
• Not considering AHSCT for appropriate candidates with aggressive disease 1
• Misinterpreting CSF findings without clinical context 4

By implementing this comprehensive management approach, patients with MS can experience improved quality of life and potentially slower disease progression.