Dr. Ann Cabot of Concord Hospital Neurology discusses multiple sclerosis and its treatment options.
Multiple sclerosis (MS) is a disease that impacts the central nervous system (CNS), which includes the brain, optic nerve and spinal cord. It is chronic and if not effectively managed, can be progressive and debilitating. MS is what is called a demyelinating disease meaning that the protective covering on nerve fibers in the CNS, called a myelin sheath, becomes damaged. A layer of cells, known as the blood brain barrier, usually separates the immune system from the CNS; however, in MS, immune cells cross the barrier and incorrectly begin to attack and destroy myelin. Myelin covers and protects the nerve fibers and allows electrical impulses to travel quickly from neuron to neuron. When the myelin is damaged, these impulses are slowed or disrupted resulting in a variety of problems.
Multiple sclerosis is what we call a snowflake disease; there is no typical patient as the disease and it’s processes manifest differently in each individual. However, MS is usually diagnosed between the ages of 15 and 45 and women outnumber men three to one. Smokers are twice as likely to develop MS versus non-smokers. It is estimated that around 1 million people in the United States alone have MS. Once diagnosed with MS, a patient is considered to have it for life. It is also important to note that there are different stages of MS. Early disease is characterized by many ups and downs resulting from inflammation causing attacks and then periods of relative recovery prompted by regeneration in damaged areas. Late in the disease process, we see predominantly degeneration with less inflammatory ups and downs, but also less regeneration and remission.
As MS is a disease of the central nervous system, a variety of visual, motor, cognitive, and sensory symptoms can be experienced. These can include weakness, numbness, depression, anxiety, loss or disruption of vision, poor coordination, trouble with balance and gait, bladder and bowel issues, and fatigue. When MS is suspected, a comprehensive exam is performed that can include gathering patient and family history, a physical exam with potential blood work, an MRI, and spinal fluid analysis. The hallmark finding of MS is focal plaques or lesions in the brain and spinal cord that present as white spots on MRI. These spots can indicate demyelination damage. MS is a diagnosis of exclusion; however, meaning other potential causes that mimic MS must be ruled out, such as vascular disease, nutritional deficits, or infections. The McDonald Criteria are guidelines that help physicians decide whether or not a diagnosis of MS is warranted.
The short answer is that we do not know. Fortunately, researchers have identified potential triggers that in combination with a genetic predisposition may result in the development of MS, such as various infectious agents or environmental toxins, obesity, low vitamin D, and tobacco smoke. Because of this knowledge and the discovery of what happens during active MS, researchers have also been able to develop numerous treatments over the last decade.
There are two main types of MS, namely relapsing-remitting multiple sclerosis (RRMS), and primary progressive multiple sclerosis (PPMS). Currently there are 20 different therapies available for RRMS and one for PPMS. These therapies vary in type from injectable to intravenous to pill form. Some examples are Betaseron, Copaxone, Tysabri, Gilenya, Ocrevus, and Lemtrada. Regardless of the treatment course chosen, patients are monitored with periodic follow-up appointments with a neurologist and repeat MRIs to determine if the medication is working.
Ann Cabot, D.O., is board-certified in neurology. Dr. Cabot recently presented on multiple sclerosis at the February Concord Hospital Trust “What’s Up Doc?” Donor Lecture Series. The monthly series, supported by the Walker Lecture Fund, features members of Concord Hospital’s medical staff speaking to Concord Hospital Trust donors about new and innovative medical treatments and services. You can watch Dr. Cabot’s presentation on Concord Hospital’s YouTube channel at: youtube.com/concordhospital.