March 16, 2006

NeuroScience Insights for Health Care Professionals

The physicians and staff of The Neuroscience Group are providing this physician and provider communication to help you stay abreast of issues and updates in the dynamic field of neurosciences, with the goal of helping you provide better overall healthcare services to your patients. Based on the level of urgency, future emails will take the form of Alerts (urgent news within the neurosciences that may impact your practice), Bulletins (important information), or Updates (more general news) and will be noted as such in the topic headline.

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Update: Multiple Sclerosis - Treatment

Because MS is an autoimmune disease, treatment aims to modulate or suppress the immune system. Rebif (interferon beta-1a), Copaxone (glatiramer acetate), Betaseron (interferon beta-1b), and Avonex (interferon beta-1a), are self-injectable drugs for long-term use; they modulate the immune system and are FDA-approved for relapsing-remitting MS.

Novantrone is an immune system suppressor, delivered by IV infusion in a medical setting. It is approved for worsening relapsing, relapsing progressive or secondary progressive MS. There are currently no FDA-approved treatments for primary progressive MS.

Tysabri is an addition to the MS armamentarium that has been in the news lately. It is a monoclonal antibody given by infusion into a vein every four weeks. This drug was on the market for four months as a therapy for relapsing MS until it was voluntarily withdrawn from the market in February 2005 due to safety concerns. Tysabri is currently being re-evaluated by the U.S. Food and Drug Administration for its possible return to market.

Monitoring with periodic laboratory tests is necessary while our patients are taking these drugs. Monitoring CBC, basic metabolic panel, and liver function tests will alert us to the most common adverse effects of these drugs. There may be additional guidelines for monitoring treatment and side effects with Tysabri if it is returned to market.

Other immunotherapy that is rarely used in patients who have intolerable side effects to the approved drugs, whose condition worsens clinically while on those drugs, or who have primary progressive MS include: pulse steroid treatments, plasmapheresis, IV IG, CellCept, methotrexate, and Cytoxan. None of these are FDA-approved for MS and their use is ?off-label?.

Acute exacerbations are caused by active inflammation in the CNS. It is sometimes difficult for patients and physicians to tell if a particular complaint is an exacerbation, a paroxysmal symptom, or a medical problem unrelated to MS. A guideline is that a symptom that is particularly debilitating or that lasts for longer than 24 hours is an exacerbation and should be treated as soon as possible. Treatment for acute exacerbations generally involves IV and/or oral steroid treatment. There is some evidence that patients who have a severe exacerbation that does not respond to steroids could respond to plasmapheresis.

Sometimes an increase in symptoms has nothing to do with the underlying MS, but is caused by factors such as fever, infection, or hot weather that can temporarily aggravate MS problems. It is always advisable to ask the patient about symptoms of infection and to test for underlying infection as that can worsen MS-related symptoms. This is referred to as a pseudoexacerbation. Once the triggering event is past?e.g., the body temperature returns to normal, the symptoms subside as well. Some people with MS report a worsening of their symptoms during or after periods of intense stress. Researchers are exploring the effects of stress on the immune system and its possible involvement in MS.

Besides needing therapy for modifying the disease itself and for acute exacerbations, MS patients have complaints that stem from their MS that need to be treated symptomatically. Fatigue is probably the most common complaint in MS. This can be ameliorated in general by good sleep hygiene, cutting back on caffeine, and increasing exercise. When medication is needed amantadine, Provigil, or sometimes Adderall can be helpful. Other MS symptoms that are difficult for patients to cope with include pain, cognitive problems like memory loss or trouble solving problems, weakness, blurred vision, numbness, prickly or tingling sensations, heat sensitivity, dizziness, and bladder or bowel problems.

At the Neuroscience Group of Northeast Wisconsin we want to work with our primary care colleagues to care for patients with MS and other neurological problems.

For more information on MS and tysabri:

www.nationalmssociety.org/tysabri.asp

www.fda.gov

www.tysabri.com

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