Multiple Sclerosis Treatments for Acute Attacks Relapses
Marsha L Tarver, PhD
What is MS?
Multiple sclerosis is a neurological disease that affects the brain and spinal cord and can affect the optic nerves. The disease damages myelin, which is the protective material covering the nerves in the brain and spinal cord. This damage produces changes in how the muscles respond to nerve stimulation by interfering with body movement and coordination. The damaged areas develop a scarring or sclerosis that continues to inhibit normal functioning. In some cases, the scarring heals and people experience more normal functioning for a time. However, over time the continual scarring can cause permanent damage to the motor and sensory areas of the brain and spinal cord.
The disease is unpredictable and, depending on the location and type of damage to the nerves, it can cause a variety of symptoms. These symptoms range from feelings of muscle weakness and numbing to loss of large muscle control. It can also affect balance, bladder and bowel function, cognitive functioning like memory, speech and swallowing, and people tend to experience more fatigue than before onset of the disease.
There is a variety of treatments for this relapsing-remitting disease and for the symptoms of MS. Medications as well as rehabilitation therapies are common approaches used to help manage the disease. Medications are commonly referred to as disease modifying therapies or treatments (DMTs). These drug therapies focus on reducing the frequency of relapses and delaying the progression of the disease by decreasing the inflammation in the nervous system. It appears that the inflammation is due to the body overdeveloping an immune response to the disease. The drugs target the inflammation and the over-reactive immune system, which in turn inhibits the myelin damage.
Currently, there are several drugs designed to interact with the immune system and “slow down” the over-reactive response. One family of medications used to slow the progression of MS is interferons. Interferons are proteins that are normally produced by the immune system. They have a wide range of functions, but generally serve to regulate the immune system. There are three types of interferon drugs. There are two interferon beta 1-a drugs, and are known by their brand names Rebif® and Avonex®. There is one interferon beta 1-b drug known by its brand name Betaseron®.
Another drug that is used is an artificial protein that resembles the natural myelin protein that protects nerve fibers. This drug is called glatiramer acetate, and is known by its brand name as Copaxone®.
There is another drug designed to suppress the immune system by slowing down or controlling inflammatory cells that cause inflammation and damage nerve cells. This drug is called mitoxantrone and is known by its brand name as Novantrone®.
Natalizumab or known by its brand name as Tysabri® also slows progression of immune cell damage.
Acute attacks are also called episodes, exacerbations, and relapses. Generally, these attacks refer to new MS symptoms or a worsening of existing symptoms. These symptoms generally appear or worsen in a short period and can have an effect upon bladder and bowel systems, small and large muscle groups, vision and other neurologic functioning. Generally, it is considered an “attack” when the symptoms last 24 hours or more. Symptoms of attacks are unpredictable and are experienced in 90% of the MS population. The average person with untreated MS will experience about one attack each year. Research shows that these attacks or relapses can be lessened with drugs.
It is important to notify health care providers when experiencing an attack or relapse. The majority of people that get early treatment for their relapse report a shorter duration of the new symptoms. Some of the approaches to treat acute attacks include steroids and plasma exchange.
In general, steroids are naturally occurring compounds that are involved with a wide range of body systems. Specifically, steroids that are used to treat MS are corticosteroids. These steroids are not related to the steroids used by body builders.
Corticosteroids, a type of steroid produced in the adrenal cortex, can reduce inflammation and affect the body’s immune response. In the case of an acute attack, corticosteroids given by injection can aid the body’s response to reduce the inflammation caused by the disease and help regulate the over-reactive immune system. The corticosteroid treatment is administered by a health care professional and generally in an outpatient setting.
People tend to tolerate short-term, high dose use of steroids with little or no side effects. Some people may experience changes in their appetite, mood changes or have a problem with sleeping and/or fluid retention. Long-term use might increase the symptoms mentioned above along with other side effects such as hypertension and diabetes. To avoid the side effects associated with long-term use, short-term, high dose use of steroids is the preferred treatment approach for patients with MS. Corticosteroid treatment approaches are considered after review of each patient’s medical history to help manage an acute attack.
Plasma is the liquid portion of blood that is made up of water, minerals, protein and antibodies, and it supports the red and white blood cells. A plasma exchange procedure, also called plasmapheresis, focuses on removing plasma, the liquid portion of blood, and replacing it with new plasma fluid. It is suspected that the antibodies in the plasma of MS patients are attacking the myelin material that acts as a protective covering over nerve cells in the brain and spinal cord.
Plasma exchange increases the chance of eliminating the harmful antibodies contained in the old plasma by replacing it with the new plasma fluid. The procedure requires that the patient be hospitalized and monitored for approximately one week, while the blood is filtered through a machine. Some side effects that might be experienced include abnormal blood clotting, the possibility of increased infection and/or allergic reactions to the new plasma. Since the plasma exchange procedure has more side effects than other MS treatments this approach is only used in cases where people have not responded to corticosteroids and are still experiencing severe attacks.
In addition to medications, depending upon symptoms experienced due to the acute attack it may be necessary to include rehabilitative treatments such as physical or speech therapy. Additional rehabilitative treatments will help with symptom management and might lessen the overall effects of the acute attack. It is highly recommended for people who are experiencing an acute attack to contact their healthcare provider to discuss the appropriate treatment response.
The VA has a myriad of services available for people with MS. Services range from medical specialists to attend to the effects of the disease to social/psychological services to help with life management of the disease. In addition, there is a variety of ambulatory equipment and adaptive devices available for the home and car. For more information, contact your local VA medical center and/or your local Veteran Service Organization.
Last Updated: October 2009