Currently, multiple sclerosis has no etiological treatment (to treat the underlying cause). Instead, knowing the pathogenic events of the disease allowed the development of therapeutic possibilities which in certain conditions increase the chances of a significant number of patients to modify the natural evolution of the sclerosis.
Thus, it is followed the interval between relapses, shorten the duration and lessen the severity of flare, reduce the accumulation of brain lesions. Also, it delays the turn to secondary progressive form and sometimes it can brake the pace of neurological invalidation.
Currently, we have therapeutic possibilities that can be grouped into the following three categories:
1. Disease evolution modifying treatment: immunomodulatory and immunosuppressive;
2. Treatment of relapses;
3. Symptomatic and recovery treatment.
Disease evolution modifying treatments
1. Immunomodulatory: interferon beta 1a, 1b beta, glatiramer acetate;
2. Immunosuppressants: mitoxantroma (Novantrone). Diagnostic evaluation and therapeutic indications should be made in centers with a neurologist specialized in multiple sclerosis. Mitoxantroma decreases the frequency of relapses and / or clinical disability and improves MRI appearance of active lesions in relapsing forms. But there is a risk of major adverse hematological effects and a severe cardiotoxicity.
Treatment of relapses
1. Corticosteroids. Glucocorticoids are a major indication for treatment of relapses in any clinical form of multiple sclerosis in large doses intravenously. It improves the speed of functional recovery of patients, decrease the duration and severity of relapse, and the number of lesions on MRI. Their use does not reduce the disability accumulated by repeated relapses. Used products: methylprednisolone (Solu-Medrol), prednisolone orally, superprednol (dexamethasone), prednisone. Their effectiveness is manifested only in the short-term and is not significantly influenced by the type of preparation, dosage or route of administration.
2. Plasmapheresis makes a non-selective filtration of plasma components with pathogenic potential (that helps disease mechanism). These components are represented by antibodies, immune complexes and complement. Plasmapheresis appears to be an alternative in patients with severe relapses, unresponsive to corticosteroids.
Symptomatic treatment and recovery
Purpose: To improve the quality of patients life with multiple sclerosis, maintaining their social integration as much as possible. Treatment is tailored according to the clinical stage of the disease and the degree of disability specific to each patient, addressing in a differentiated mode to each clinical aspect of the disease.
- Physiotherapy. Maintaining postural stability, preserving and improving mobility through regular exercise, prevent contractures, maintaining correct position, correct use of orthoses, walking sticks and remedial gymnastics.
- Occupational therapy. It is made by a multidisciplinary team that addresses all daily activities of the patient, aimed at keeping the patient engaged in social activities and maintaining its independence in self-care (as much as possible).
- Sphincter disorders. Requires measuring of urine flow and determination of residual urine. In small and spastic bladder is administered oxibutine, tolperidine. In a large, flaccid bladder is used a mechanical drainage by intermittent or fixed bladder Catheterization. In neurogenic bladder resulting in imbalance between sphincters and the detrusor – is difficult to treat – combination of anticholinergics or botulinum toxin injection.
- Bowel disorders. (Constipation, fecal incontinence, diarrhea). It is treated by changing the type of diet (increased dietary fiber in constipation or eliminating beverages and foods that cause diarrhea). The use of drugs and appropriate medical maneuvers – suppositories, enemas in case of constipation, diarrhea medication in case of diarrhea.
- Chronic Fatigue. For a correct attitude is necessary to set the time of fatigue. Administer an appropriate treatment: amantadine, fluoxetine.
- Spasticity. General measures, which is to identify what factors are worsening it (relapses, urinary infections, bowel disorders, interferon beta), physiotherapy, proper medication: baclofen, tizanidine.
- Sexual dysfunction. Careful identification of the cause of these disorders is the major route for a specific therapeutic approach. Medication: sildenafil citrate, prostaglandin E1, papaverine.
- Pain. Identifying the cause (neurogenic pain – due to multiple sclerosis, pain is due to either a urinary infection or a bladder spasticity or immobilization in bed. Physiotherapy and medication: gabapentin, carbamazepine, amitriptyline, pregabalin.
- Tremor. Treatment is difficult and with limited efficacy. Occupational therapy and rehabilitation, medication: propranolol, clonazepam.
- Recovery of language. Dysarthria is relieved by respiratory gymnastics, accompanied by velo-pharyngeal stimulation. Aphasia requires lexical and semantic exercises, both oral and written.
- Swallowing disorders. Minor, but frequent in the early stages of the disease and should be evaluated early to prevent further severe complications (activation techniques of chewing and swallowing reflexes, compensatory techniques, special postures).
- Cognitive impairment. As are a consequence of primary axonal lesions and neuronal loss followed by cerebral atrophy – the most important way of preventing these events is to use earlier and more sustained the disease-modifying therapy . Their assessment involves clinical and neuropsychological regular examination and continuous cooperation with the patient’s family.
- Psychological treatment. It is made according to their emotional, cognitive and social aspects. The needs are different at each stage of the disease. Psychotherapy is associated with antidepressants – amitriptyline, fluoxetine, venlaflaxine.