MANAGEMENT OF MS
This is probably the most important part of MS for patients and for general readers. I don’t think it is the most important part for the neurologists, as the main job for any neurologist is to reach a diagnosis. Once the diagnosis is made, any one can talk about treatment especially in today’s world were it is so easy to check the internet and get an answer almost for every thing !.
I will go through the available treatments for MS with some information about each one of them with the latest updates.
I will leave any advances in the management, and current research activity to the next page which is devoted for the latest advances in the management of MS.
I will also give updated information about the currently non-licensed medications many people with MS are using either privately or out of license.
As I always believe in treating our patients as human beings, but not diseases, I will start with an approach to dealing with any person who suffers from MS, especially those who are newly diagnosed.
Managing patients with MS
- Multidisciplinary Approach
- Treatment of exacerbation (relapses)
- Treating complications
- Disease modifying therapy (DMT)
Before I start writing about management process I would like to consider mentioning in this space more about MS itself in relation to management options and choices.
I need to mention here that MS is not an inflammatory disease only even in its very early relapsing and remitting status, and even on the first day when we (doctors) see the patient. MS is in reality a combination of inflammation (nerve sheath) and degeneration (nerve fiber). Inflammation is reversible if treated at the right time, but degeneration is permanent once it was left to happen.
Let me remind you and myself with the old classification of MS which I think is not correct any more and must be updated in my view. The time is going on and moving forward, and we definitely need to move on with it if we seriously aim to beat MS. I think MS will be cured one day, and that day is not going to be too far to wait for. I have already heard high authority professionals in MS management saying that in about 8 – 10 years we will be able to cure MS. Within a decade or even may be less; it is not a long time to wait for !.
The old classification of MS was:
- Relapsing & remitting.
- Secondary progressive.
- Primary progressive.
Secondary progressive MS (SPMS) can be with or without relapses depending on the elapsed time and the degree of degeneration.
That classification was not correct in the beginning, and it is not correct anymore , because it was based on our old understanding of MS. I am talking about 40 – 50 years, during which a revolution in understanding MS has happened. The revolution in knowing more about MS was not reflected on its classification.
Let me show you this diagram to prove what I am talking about here:
There is nothing called secondary progressive MS de novo. Secondary progressive MS is obviously a secondary process following a primary one !. Secondary progressive type of MS can never be a separate class of MS. It is a process during which relapsing & remitting MS gets older and becomes a secondary progressive type.
We can probably say there are two types of MS
- Relapsing & remitting MS, leading to secondary progressive MS of two types:
a- SPMS with relapses. b- SPMS with no relapses.
2. Primary progressive MS.
What about other rarer types of MS such as the clinically isolated syndrome (CIS), and the benign MS ?.
CIS is the first presentation of MS symptoms with radiological features are highly suggestive of MS, but the neurologist is unable to make a definite diagnosis of MS at that stage. That stage is called CIS, and in a good place with enough experience at 50% will become definite MS in due time. I think that should be considered a separate class of MS.
Another type of MS presents in the beginning with symptoms suggestive of MS, and the MRI changes are classical of MS, but the patient remain very well with no significant progression over about 10 – 15 years, or may be even longer.
About 2-5% of diagnosed MS may lie withing this group. This must be considered a separate class.
Hence, in my view the new classification of MS must be:
There is another earlier phase of likely to be definite MS, that phase is known as Radiologically Isolated Syndrome or otherwise known as RIS. It may be considered in the future as a 5th. class of MS.
In general, almost all RRMS will progresses over time, and the 5 year interval may be considered as a reliable guide line:
- In 05 years from diagnosis, about 50% of RRMS will be SPMS.
- In 10 years from diagnosis, about 75% of RRMS will be SPMS.
- In 15 years from diagnosis , about 95 – 98% of RRMS will be SPMS.
The other 2-5% of RRMS which does not progress any further at that time can be considered BMS in my view.