Treatment

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Before the 1990s there was no treatment that could alter the course of multiple sclerosis (MS). Steroids, which suppress the immune system, were used to treat exacerbations (when at least one symptom occurs, or worsens, for more than 24 hours, lasting for days, weeks, months or indefinitely), but the effectiveness of long-term use of these drugs hasn't been established, and long-term use produces severe side effects.

The outlook brightened in 1993, with the introduction of Betaseron, the first disease-altering drug for relapsing-remitting MS. In 2006, the labeling of Betaseron was expanded to include patients who have experienced a first episode and who have an MRI result consistent with multiple sclerosis. Two other medications, Avonex and Copaxone, followed in 1996. These three treatments have revolutionized the way relapsing-remitting MS is treated. These drugs do not stop MS entirely or cure it, but they do reduce the frequency and intensity of attacks and slow the progress of damage.

Interferon beta-1b (Betaseron) and interferon beta-1a (Avonex) are biotechnology drugs based on a natural human protein that dampens immune system activity. The third disease-altering drug, glatiramer acetate (Copaxone), works by a different mechanism: it looks like myelin to the immune system and acts as a decoy. All three are injected drugs. Your health care professional will instruct you or a caregiver on medication preparation and self-injection.

In 2002, the U.S. Food and Drug Administration (FDA) approved a third form of interferon called Rebif. Like Avonex, Betaseron and Copaxone, it is indicated for the treatment of patients with relapsing forms of MS to decrease the frequency of clinical exacerbations and delay physical disability. Like Avonex, Rebif is the beta-1a form of the human protein interferon. However, unlike Avonex's once a week, intramuscular injection regimen, Rebif is injected three times a week subcutaneously. It is now used as a first-line treatment, on par with the disease-altering drugs that were approved before it.

Key facts about disease-altering drugs used to treat MS:

• Avonex is injected by deep intramuscular injection once a week. Side effects include flu-like symptoms following the injection, which lessen over time. Rarer side effects include mild anemia and elevated liver enzymes, which may indicate liver inflammation.

• Betaseron is injected every other day under the skin. Side effects include flu-like symptoms following injection, which lessen over time, and injection site reactions, about five percent of which need medical attention. Rarer side effects include elevated liver enzymes and low white-blood-cell counts, which make a person susceptible to infection.

• Copaxone is injected daily. Injection site reactions are the most common side effects. Other, rarer side effects include a reaction immediately after injection that includes anxiety, chest tightness, shortness of breath and flushing; this lasts a few minutes and has no known long-term effects. About 13 percent of people taking Copaxone will experience this reaction at one time or another.

• Rebif is injected three times a week, with the same side effects of other interferons (Avonex and Betaseron).

Note: Talk to your health care provider if you experience side effects from one of the above-mentioned drugs. There may be strategies you can use to minimize the side effects, they may abate in a few months, or you may be able to switch to one of the other drugs and avoid the side effects. If you stop taking the drug, it may seem like there are no consequences, but MS damage can occur steadily and silently for long periods before the next attack.

In 2006, the FDA approved a new biologic treatment called natalizumab (Tysabri). It is a monoclonal antibody bioengineered from part of a mouse antibody to closely resemble a human antibody and is approved for patients with relapsing forms of the disease to reduce the frequency of symptom flare-ups or disease exacerbations. The treatment is given intravenously (into a vein) once a month in a physician's office. It is the first monoclonal antibody approved for the treatment of MS. In clinical trials, the most frequently reported serious adverse reactions were infections, including pneumonia, temporary hypersensitivity reactions (such as rash, fever, low blood pressure and chest pain), depression and gallstones. These serious adverse reactions were uncommon. Common adverse reactions were generally mild and included non-serious infections (such as urinary tract, lower respiratory tract, GI system and vaginal infections), headache, depression and joint pains. However, three cases of a fatal viral disease, progressive multifocal leukoencephalopathy, were discovered in Tysabri patients, changing the use of this medication to specific situations where other treatments have failed.

In October 2000, mitoxantrone (Novantrone) was approved for reducing disability and/or the frequency of clinical relapses in patients with secondary progressive MS, progressive-relapsing MS or worsening relapsing-remitting MS. It is a potent immune-suppressing agent that acts by suppressing the activity of T-cells, B-cells and macrophages that are thought to lead the attack on the myelin sheath. The drug is given intravenously (into the vein), once every three months. Short-term safety and tolerability of Novantrone in MS appear to be manageable. Common side effects include nausea, hair loss, urinary tract infections and menstrual disorders (in females). The longer-term safety of Novantrone in MS, particularly its impact on cardiac (heart) function and leukemia, may be problematic and limits the use of the drug for two to three years in a lifetime.

Steroids such as methylprednisolone often are prescribed to treat acute attacks of MS, whether the patient is taking a disease-altering drug or not. These drugs speed the recovery from the acute attack but do not stop disease progression. Long-term use of steroids also has many side effects, including ulcers, weight gain, acne, cataracts, osteoporosis and diabetes.

Chemotherapies that suppress the immune system broadly and were originally designed to treat certain cancers are sometimes used for progressive MS. In addition to Novantrone, cyclophosphamide (Cytoxan) and azathioprine (Imuran) are used similarly but do not have approval from the FDA for treatment of MS.

A process in which the antibodies are filtered from a person's blood called plasmapheresis may be successful, particularly when used in combination with immunosuppressants for short-term treatment of some progressive patients. However, its use is controversial.

For symptom management, health care professionals have an arsenal of medications. For example, baclofen (Lioresal) and tizanidine (Zanaflex) are antispasticity medications often prescribed to relieve muscle spasms, cramping and tightness of muscles in MS patients. Each has varying side effects in varying degrees. Your health care professional should be able to find one that provides comfort and relief for almost any symptom you have.

Although currently unapproved by the FDA for MS patients, a growing number of health care providers now consider use of the botulinum toxin (Botox) as an effective short-term treatment option for certain types of MS-related problems, such as muscle stiffness and urinary problems, when first-line treatment is ineffective.

Non-medical strategies for coping with MS

An MS diagnosis doesn't have to stop your life, but you will have to learn—and practice—strategies for managing fatigue and dealing with other temporary or long-term disabilities. Physical and occupational therapists can help you develop strategies and select assistive devices to navigate the workplace and home environment.

Physical therapy usually focuses on walking (including using ambulatory aids correctly), balance and stability in standing, maintaining range of motion and functional strengthening. Occupational therapy focuses more on ways to accomplish specific everyday tasks at home and work, as well as managing your energy. Some programs include techniques to improve memory and concentration.

Check your health plan for coverage. Not all cover physical and occupational therapy.

Symptoms that affect your memory and concentration may be the most painful to talk about. But acknowledging these symptoms and discussing them with health care professionals and your family are the first steps toward getting them under control. The National Multiple Sclerosis Society can direct you toward support groups and publications that can help. Visit its Web site at www.nationalmssociety.org.

Things you can do at home to manage fatigue and/or limited mobility include:

• Declutter your living areas.

• Divide household tasks more equitably with family members.

• Simplify tasks like cooking so they are less stressful. For example, cook more frozen vegetables or freeze individual servings of a meal, so you can give yourself time off from meal preparation.

• Make tasks less fatiguing. For example, put a table and chair in the kitchen so you can sit while cutting or stirring.

• Identify and abide by your priorities. If it's important for you to continue working, take some shortcuts with household tasks, or eliminate some of them.

• Cut back on tiring leisure activities, or make energy-conserving adaptations (such as planting a smaller garden).

• Minimize or combine trips.

At work you may want to try the following:

• Manage your workload to accommodate fatigue. For example, if you feel good in the morning but tire rapidly in the afternoon, do your most demanding work in the morning.

• Ask your employer about flex time.

• Consider multiple short breaks instead of an hour-long lunch. Perhaps a 30-minute lunch and two 15-minute breaks.

• When you're having trouble concentrating, close your office door or take your work to a quiet area, if possible.

"Journaling" can also be a helpful coping strategy. A written or recorded account can help you keep track of when symptoms occur, the management tools that work best for specific symptoms, your medication schedule and many other issues related to your condition. Recording your thoughts and feelings may also be helpful to you.

Exercise can be therapeutic and is at least as important for women with MS as for other women. If you have MS, the last thing you want is to develop other health problems—such as obesity, diabetes or heart disease.

People with MS, however, should not "go for the burn" during exercise because overheating can trigger symptoms and worsen fatigue. Some women with MS enjoy exercising in a cool pool, but others find that the bother of driving and changing twice is too fatiguing. A physical therapist can help you design an appropriate exercise program.