How treatment and management of MS has changed over the years, and what’s next.
By Benjamin Segal, MD, told to Kara Mayer Robinson
We have come a long way in the treatment of multiple sclerosis – it is one of the greatest successes in medicine. Over the past 20 years, there has been a revolution in drugs that alter the course of the disease, particularly relapsing-remitting multiple sclerosis (RRMS).
When I was in training, we didn’t have any medications that would alter the prognosis for MS or prevent seizures. The only thing we had were steroids. We gave them to people in severe attacks to speed up recovery. But we had nothing to reduce a person’s chances of developing the disease. We also couldn’t stop future attacks, delay the disability, or make it less severe.
Now, there are over 15 FDA approved drugs that do just that. They include injections that you can give yourself, pills, and intravenous infusions. But they differ in their effectiveness and side effects. And we have no way of predicting which patient will respond best to which drug.
The focus of MS specialists now is what we call “no disease activity”. This means no relapse, no new injury and no continued development of disability. For many patients, we can achieve this, especially those with RRMS.
There have also been changes in the way we think about secondary progressive multiple sclerosis (PMSD). In recent years, three drugs have been approved for RRMS and SPMS. Before that, there were no drugs approved for PMSC except for very strong chemotherapy which we no longer use.
We now have evidence that early treatment, and in particular treatment with certain drugs, can delay the conversion of RRMS to SPMS. In some cases, patients do not show a gradual decline over decades.
What’s new on the horizon
Many new therapies are being explored to further advance the treatment of MS. Two important areas of study are the promotion of repair of MS and how to treat progressive MS.
Remyelination and repair
In people with MS, myelin is broken down, causing many symptoms. Researchers are studying different strategies to help the body form new myelin, the protective coating around nerves.
Some clinical trials target molecules that normally suppress the growth of myelin. Researchers are now studying a protective or pro-regenerative part of the immune system that we can manipulate to protect damaged neurons and stimulate the growth of new fibers.
My group at Ohio State University just published an article about our discovery of an immune cell that saves damaged nerve cells from death. It also stimulates the regrowth of nerve fibers. It can not only stop further damage to the central nervous system, but it can also reverse the damage and restore function.
Treat secondary progressive MS
We have made progress with SPMS drugs, but there is still a long way to go.
Data suggests that three recently approved drugs for PMSC are quite effective in a subset of younger people who still have new inflammatory lesions. But they are unlikely to help those who are more advanced with the disease. The quest is therefore to find treatments for these people.
A few pills tested in trials show promise. One of them suppresses immune cells that are normally found in the brain and spinal cord. This prevents the body from activating them. In a recent phase II trial, it slowed the progression of disability in people with inactive and progressive MS.
Finding the right treatment for each person
At this time, we cannot predict which patient will respond best to which drug. But there are many studies going on that predict which drug will work best in a particular individual. Researchers are also looking for biomarkers to develop blood tests that could tell us if someone is more likely to respond to one drug than another.
Vitamin D, antioxidants and the gut microbiome
Some studies show that very low levels of vitamin D increase your chances of developing MS. Now, there are studies to see if increasing vitamin D levels with additional supplements can alleviate new seizures or lesions in people who already have it.
There are also studies that look at the gut microbiome and determine if you can better manage MS by changing the bacteria in your gut.
It’s not yet conclusive, but researchers are investigating whether certain antioxidants can affect the treatment or management of MS. One is called lipoic acid. A few studies suggest that it may slow the loss of brain tissue in people with MS. There will likely be future studies that will look at lipoic acid and other antioxidants in more detail.
New ways to manage symptoms
One of the most common and difficult to manage symptoms of MS is fatigue. There are studies on pills and cognitive rehabilitation therapy to treat it. There is also a lot of research into improved prosthetics and robotics to help patients with MS function better.
Early and aggressive treatment
Now that we have very powerful drugs to treat MS, there is a debate as to whether it is better to start treatment early with aggressive drugs or to start with weaker drugs and then move on to more drugs. powerful.
A recent study suggests that people treated with stronger medications early on are less likely to switch to PMSC years later. New studies comparing aggressive early treatment to escalation therapy may help us find out more.
Right now, many of my MS patients are living fully. I have seen people without relapse for 2 decades without new lesions. No one would know they have MS.
This is a completely different situation from when I was a resident in training. Then most of the people we saw needed assistive devices and had to stop working.
I think there will be progress in the next 5-10 years that brings us even closer to a cure. It is very difficult to predict. We are more likely to find treatments that help relapsing-remitting disease and possibly stop the progression of the disease altogether. A cure may take a little longer.
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