What are the management options for multiple sclerosis?

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 (DMTs)

First-Line Approach

1. Early intervention is critical to prevent accumulation of disability
2. Selection of DMT should be based on:
   • Disease subtype (relapsing-remitting vs. progressive)
   • Disease severity and activity
   • Patient characteristics (age, comorbidities)
   • Risk tolerance

Treatment Algorithm by MS Type

Relapsing-Remitting MS (RRMS)

• Mild-Moderate Disease:

  • Oral agents (dimethyl fumarate, teriflunomide, fingolimod)
  • Injectable therapies (interferons, glatiramer acetate)

• Highly Active Disease:

  • Monoclonal antibodies (natalizumab, ocrelizumab, ofatumumab)
  • Consider natalizumab with appropriate JCV antibody monitoring 2
  • Cladribine or alemtuzumab for aggressive disease

• Treatment-Refractory Disease:

  • AHSCT after failure of high-efficacy DMTs 3, 1
  • Most effective in RRMS and early secondary progressive MS 1

Progressive MS

• Secondary Progressive MS with Activity:

  • Siponimod, ocrelizumab
  • Consider AHSCT in early stages with inflammatory activity 1

• Primary Progressive MS:

  • Ocrelizumab
  • Benefits of AHSCT less clear 1

Monitoring Disease Activity

1. Clinical monitoring:

   • Evaluate every 3-6 months initially, then every 6 months 2
   • Assess for new symptoms, relapses, and disability progression

2. MRI surveillance:

   • Baseline MRI before initiating therapy 2
   • Follow-up MRIs at regular intervals (typically annually)
   • Use standardized protocols with gadolinium enhancement to identify active inflammatory lesions 1
   • Consider more frequent monitoring for high-risk patients

3. Laboratory monitoring:

   • Drug-specific monitoring protocols
   • JCV antibody testing for patients on natalizumab 2

Symptom Management

A comprehensive approach to symptom management is essential for quality of life 4, 5:

Spasticity

• Physical therapy, stretching
• Pharmacologic: Baclofen, tizanidine, dantrolene, gabapentin
• Severe cases: Intrathecal baclofen, botulinum toxin

Fatigue

• Energy conservation strategies
• Exercise programs
• Pharmacologic: Amantadine, modafinil, armodafinil

Mobility and Balance

• Physical therapy
• Assistive devices
• Fall prevention strategies

Bladder Dysfunction

• Anticholinergics for urgency/frequency
• Intermittent catheterization for retention
• Treatment of urinary tract infections

Bowel Dysfunction

• Dietary modifications
• Scheduled bowel program
• Pharmacologic: Stool softeners, laxatives

Sexual Dysfunction

• Counseling
• Pharmacologic: Phosphodiesterase-5 inhibitors for erectile dysfunction
• Lubricants for vaginal dryness

Cognitive Dysfunction

• Cognitive rehabilitation
• Compensatory strategies
• Pharmacologic: Consider stimulants

Depression and Anxiety

• Psychotherapy
• Pharmacologic: SSRIs, SNRIs
• Support groups

Pain

• Neuropathic pain: Gabapentin, pregabalin, duloxetine, tricyclic antidepressants
• Musculoskeletal pain: Physical therapy, NSAIDs

Multidisciplinary Care

Implementation of MS Care Units is recommended for optimal management 6:

• Core team:

  • MS neurologists
  • MS nurses
  • Neuropsychologists
  • Physical therapists
  • Occupational therapists

• Extended team:

  • Urologists
  • Psychiatrists
  • Pain specialists
  • Social workers
  • Speech therapists

Common 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

Special Considerations

Pregnancy Planning

• Discuss family planning early
• Most DMTs require discontinuation before conception
• Some DMTs require washout periods before conception

Progressive MS Management

• Focus on symptom management and function preservation
• Limited DMT options but consider ocrelizumab for PPMS
• Rehabilitation is crucial

Breakthrough Disease

• Reassess diagnosis and adherence
• Consider switching to higher efficacy DMT
• Consider AHSCT in appropriate candidates