Using information from the National
MS Society’s website -- a valuable source for information about diagnosis,
management and life with multiple sclerosis (MS) --the October 2015 MS/Cancer
conference call discussed MS diagnosis, symptoms and medication. Here is a
summary of our discussion. This information can be found in more detail on the
national website at www.nationalmssociety.org/What-is-MS/Types-of-MS/Primary-progressive-MS/Research-in-Primary-Progressive-MS.
Both the National MS Society
and the American Cancer Society sponsor the MS/Cancer call.
Criteria for a diagnosis of MS
No symptoms, physical
findings or laboratory tests can by themselves determine if a person has MS.
Different approaches can determine if a person meets the long-established
criteria for a diagnosis of MS and to rule out other possible causes of
symptoms the person is experiencing. These strategies include a careful medical
history, a neurologic exam and various tests including magnetic resonance
imaging (MRI), evoked potentials (EP) and spinal fluid analysis.
To make a diagnosis of MS,
the physician must meet these three criteria:
Find evidence of
damage in at least two separate areas of the central nervous system (CNS),
which includes the brain, spinal cord, and optic nerves
that the damage occurred at least one month apart
Rule out all
other possible diagnoses.
The four types of MS are as follows:
Relapsing-remitting MS (RRMS)
RRMS is the most common
disease course and is characterized by clearly defined attacks of worsening
neurologic function. These attacks, which are also called relapses, flare-ups
or exacerbations, are followed by partial or complete recovery periods
(remissions), during which symptoms improve partially or completely and there
is no apparent progression of disease. Approximately 85 percent of people with
MS initially are diagnosed with relapsing-remitting MS.
Secondary-progressive MS (SPMS)
The name for this course
comes from the fact that it follows after the relapsing-remitting course. Most
people who initially are diagnosed with RRMS will eventually transition to
SPMS. This means that the disease will begin to progress more steadily although
not necessarily more quickly, with or without relapses.
Primary-progressive MS (PPMS)
PPMS is characterized by
steadily worsening neurologic function from the beginning. Although the rate of
progression may vary over time with occasional plateaus and temporary, minor
improvements, there are no distinct relapses or remissions. About 10 percent of
people with MS are diagnosed with PPM.
Progressive-relapsing MS (PRMS)
PRMS, the least common of
the four disease courses, is characterized by steadily progressing disease from
the beginning and occasional exacerbations along the way. People with this form
of MS may or may not experience some recovery following these attacks; the
disease continues to progress without remissions
following U.S. Food and Drug Administration (FDA)-approved disease-modifying
agents reduce disease activity and disease progression for many people with
relapsing forms of MS, including relapsing-remitting MS, secondary-progressive
and progressive-relapsing MS in those people who continue to have relapses.
- Injectable medications
- Avonex (interferon beta-1a)
- Betaseron (interferon beta-1b)
- Copaxone (glatiramer acetate)
- Extavia (interferon beta-1b)
- Glatopa (glatiramer acetate, a generic equivalent
of Copaxone 20mg dose)
- Plegridy (peginterferon
- Rebif (interferon beta-1a)
- Oral medications
- Aubagio (teriflunomide)
- Gilenya (fingolimod)
- Tecfidera (dimethyl fumarate)
- Infused medications
- Lemtrada (alemtuzumab)
- Novantrone (mitoxantrone)
- Tysabri (natalizumab)
In a National MS Society
Learn on Line video, Dr. Benjamin Segal discusses the progressive form of MS.
Dr. Segal is a professor at The University of Michigan and directs the Multiple
Sclerosis Center and at the Holtom-Garrett Program in Neuroimmunology. The
video can be found on the MS National Society website at http://www.nationalmssociety.org/What-is-MS/Types-of-MS/Primary-progressive-MS/Research-in-Primary-Progressive-MS.
Segal said in the video
that, “Progressive MS begins with neurological symptoms that can vary from
attack to attack.” He said that the patient’s health may go back to his or her
base line. Then the patient may enter a second stage and get gradually worse
with a particular symptom. Most patients experience a slow, steady decline
secondary progression. Dr. Segal said, “Tempo is important in terms of
disability they experience.”
Segal said that many MS
patients might not be able to say when their symptoms got worse. They might not
be able to pinpoint the date but they know they are not as well.
Segal discussed chemotherapy
treatment for patients. He said, “Some of my patients see benefits from
intermittent steroid treatments. Sometimes we will give a steroid once a month
and this seems to help stabilize patients. Not everyone responds and this has
not been proven in rigorous clinical trials because they haven’t been done.”
However, Segal said a great
deal of research going on such as developing drugs to help the body recover
from damage from progressive MS; to how the nervous system may block nerve
cells from regenerating; and looking into how to interfere with that process to
allow the nerve cells to regrow.
The National MS website reports that people who have
received a diagnosis of PPMS are often frustrated by the relatively small
number of clinical trials in PPMS compared
to the large number in RRMS. MS clinicians and researchers share this
frustration and are working to increase the number of trials of treatments for
PPMS. Some of the obstacles are as follows:
- The disease modifying medications currently used to treat relapsing
forms of MS primarily target inflammation in the central nervous system.
Because inflammation plays a much smaller role in PPMS than in relapsing
forms of MS, these medications do not seem to be as effective in PPMS,
which means that new treatment targets need to be identified.
PPMS, there is a lack of easily identifiable outcomes to measure in
clinical trials. In the trials for the approved disease-modifying
therapies, investigators looked at outcomes such as number of relapses and number of new lesions seen
on magnetic resonance imaging to
determine if people who received the treatment had lower numbers than
those who received a placebo. The outcome measurements do not adequately
quantify disease progression in the PPMS group.
progression in PPMS can be quite slow, making the ability to identify an
effect on progression difficult in a two- or three-year trial.
Researchers are working
to understand why some people experience aggressive worsening of MS and others
experience a milder course, and to identify other ways to measure the changes
that occur in PPMS so that they can more easily test potential treatments.
For more information, go to www.nationalmssociety.org.