Does multiple sclerosis (MS) exhibit a relapsing-remitting course with exacerbations and remissions?

From the Guidelines

Multiple sclerosis (MS) is characterized by a pattern of exacerbations and remissions, with the relapsing-remitting form being the most common, affecting about 85% of patients initially. This pattern is evident in the study by 1, which shows that patients with relapsing-remitting MS can experience a stable T2 lesion load (T2LL) during the first 3 years of treatment, but a marked increase in T2LL at the fourth year after treatment discontinuation, associated with clinical activity. The study also highlights the importance of brain atrophy measures, such as brain parenchymal fraction (BPF), in monitoring disease progression.

Key Points

• The relapsing-remitting form of MS is characterized by exacerbations, which are episodes of new or worsening neurological symptoms, and remissions, which are periods of partial or complete recovery.
• During exacerbations, patients may experience a range of symptoms, including vision problems, muscle weakness, numbness, tingling, balance issues, or cognitive difficulties.
• Remissions occur when symptoms partially or completely resolve, though some residual deficits may remain after each attack.
• The pattern of exacerbations and remissions in MS is due to the autoimmune nature of the disease, where the immune system mistakenly attacks the protective myelin sheath around nerve fibers in the brain and spinal cord, causing inflammation and damage.
• Disease-modifying therapies, such as interferon beta, glatiramer acetate, fingolimod, ocrelizumab, and others, aim to reduce the frequency and severity of relapses and slow disease progression.

Monitoring Disease Progression

• The study by 1 highlights the importance of monitoring brain atrophy measures, such as BPF, in addition to T2LL, to assess disease progression.
• The study by 1 provides consensus guidelines on the use of MRI in MS, including the use of criteria such as the number of active lesions, relapses, and disability progression to predict disease outcome.
• These guidelines can help clinicians make informed decisions about treatment and monitoring strategies for patients with MS.

Treatment Strategies

• The goal of treatment in MS is to reduce the frequency and severity of relapses, slow disease progression, and manage symptoms.
• Disease-modifying therapies, such as interferon beta, glatiramer acetate, fingolimod, ocrelizumab, and others, are effective in reducing relapse rates and slowing disease progression.
• Clinicians should consider individual patient factors, such as disease severity, treatment history, and risk of progressive multifocal leukoencephalopathy (PML), when selecting a treatment strategy.

From the FDA Drug Label

TYSABRI is indicated as monotherapy for the treatment of relapsing forms of multiple sclerosis, to include clinically isolated syndrome, relapsing-remitting disease, and active secondary progressive disease, in adults. REBIF is indicated for the treatment of relapsing forms of multiple sclerosis (MS), to include clinically isolated syndrome, relapsing-remitting disease, and active secondary progressive disease, in adults.

The multiple sclerosis types mentioned (relapsing-remitting disease) imply that the disease can have periods of exacerbations and remissions.

• Exacerbations are when the disease is active and symptoms worsen.
• Remissions are when the disease is not active and symptoms improve. This pattern of exacerbations and remissions is consistent with the concept of the disease waxing and waning. Therefore, multiple sclerosis can indeed wax and wane with exacerbations and remissions 2 3 3.

From the Research

Multiple Sclerosis Disease Course

Multiple sclerosis (MS) is a chronic and often disabling autoimmune disease that affects the central nervous system. The disease course of MS can vary significantly from person to person, but it is commonly characterized by:

• Exacerbations or relapses: Episodes of new or worsening symptoms that can last from a few days to several weeks or even months.
• Remissions: Periods of partial or complete recovery between exacerbations, during which the disease does not progress.
• Progression: A steady worsening of the disease over time, which can occur with or without exacerbations.

Treatment of Multiple Sclerosis

Several disease-modifying therapies (DMTs) are available to treat MS, including:

• Interferon beta-1a and beta-1b: These medications have been shown to reduce the frequency and severity of exacerbations and slow the progression of disability in people with relapsing-remitting MS (RRMS) 4, 5, 6.
• Other immunomodulators and immunosuppressants: Such as natalizumab, fingolimod, and teriflunomide, which have been shown to be effective in reducing relapses and slowing disability progression in people with RRMS 7.
• Treatment of progressive MS: Some medications, such as rituximab and interferon beta-1b, may be effective in reducing relapses and slowing disability progression in people with progressive MS, although the evidence is limited and more research is needed 8.

Disease Course and Treatment Response

The disease course of MS can be influenced by treatment, with some medications able to reduce the frequency and severity of exacerbations and slow the progression of disability. However, the response to treatment can vary significantly from person to person, and some people may experience a more aggressive disease course despite treatment. Factors that can influence the disease course and treatment response include:

• Disease subtype: People with RRMS tend to respond better to treatment than those with progressive MS.
• Disease severity: People with more severe disease may be less likely to respond to treatment.
• Treatment adherence: Adherence to treatment is critical to achieving optimal outcomes, and non-adherence can lead to reduced treatment efficacy and increased disease activity.