Multiple sclerosis medical therapy

The predominant therapy for multiple sclerosis is disease-modifying treatment in relapsing-remitting multiple sclerosis, immunosuppressive threpay in progressive multiple sclerosis and Glucocorticoid therapy in acute exacerbation.

The predominant therapy for multiple sclerosis is:

Relapsing-remitting type of MS can be treated with disease modifying therapy (DMT) in order to reduce the rate of attack and disease progression.^[1][2]

• Natalizumab: This drug works as an antibody against alpha 4 subunit of integrin. As a result of Blood brain barrier disruption, inflammatory cells like lymphocytes and monocytes can access the brain parenchyma and start the process of inflammation and destruction. Integrin 4 is on the surface of these inflammatory cells and helps their adhesion to vascular endothelium. Based on some studies using this drug can reduce signs, symptoms and relapses of the disease.^[3][4][5][6]

• Alemtuzumab: This drug is a monoclonal antibody and can cause reduction in CD52-expressing T cells, B cells, natural killer cells and monocytes. The side effects of this drug includes: infection, autoimmune disorders and infusion reaction.^[7][8][9]

• Ocrelizumab: Ocrelizumab is a monoclonal antibody against CD20 causing B cells depletion.^[10] It can reduce gadolinium-enhancing brain lesions on MRI of MS patients.^[11]

• Mitoxantrone: This drug has serious side effects including cardiac toxicity, so it’s more like a reserve drug for patients who don’t respond to other therapies.^[12]

• Interferons: 1. Interferon beta-1b: This drug is a cytokine that can affect immune system and modulates it and cause reduction in the progression of the disease.^[13][14] 2. Interferon beta-1a: Both Intramuscular and Subcutaneous interferon beta-1a can reduce disease progression, MRI lesions and acute attacks.^[15][16]
• Glatiramer: Glatiramer is made from four amino acids and structurally similar to myelin basic protein. It binds to major histocompatibility complex molecules and competes with myelin antigens for T cell presentation.^[17] this drug can reduce relapse rate of the disease.^[18]
• Daclizumab: It is a monoclonal antibody against alpha chain of interleukin 2 receptor. It can reduce the relapses in MS patients.^[19]

• Dimethyl fumarate: Fumarates is a neuroprotective and immunomodulatory drug which can reduce acute attacks and progression of multiple sclerosis.^[20][21][22]

• Teriflunomide: This drug inhibits the biosynthesis of pyrimidines and reduces the interaction between antigen presenting cells and T cells.^[23] teriflunomide can reduce relapse rate and disability progression of MS disease.^[24][25] The most common side effects of this drug are nausea, diarrhea and elevated aminotransferase level.^[24][26][27]
• Fingolimod: Fingolimod is an analog of sphingosine and can reduce lymphocyte migration and acute relapses of the disease.^[28][29]

• Studies show that immunosuppressive threpay includes Total lymphoid irradiation, cyclosporin, Methotrexate, Cladribine, Cyclophosphamide, Mitoxantrone, Azathioprine, Interferon, Corticosteroid, Intravenous immunoglobulin, Plasma exchange, bone marrow transplant, Anti-integrin antibodies (natalizumab) can be beneficial in progressive and sever case of multiple sclerosis.^{[30][31][32][33][34][35][36][37][38][39][40][41][42][43][44][5]}

• Management of acute attacks of multiple sclerosis may help patients to recover faster but has no effect in long term signs and symptoms.^[45][46]
• Glucocorticoid therapy: We commonly use 500 to 1000 mg of methylprednisolone daily.^[47]
• The side effects of this therapy include depression or mania, infection and GI disturbance.^[48]
• Multiple studies demonstrate that plasma exchange can be beneficial in acute attacks of multiple sclerosis too.^[43][49]

• Bladder dysfunction: Bladder dysfunction due to detresor overactivity can be treated with antimuscarinic and anticholinergic drugs such as oxybutynin, tolterodine, propantheline, propiverine, fesoterodine, and solifenacin.^[50][51]

• Sexual dysfunction: The very first step in treating sexual dysfunction is to treat neuropathic or visual pain and spasticity. These are the main causes of sexual dysfunction. Phosphodiesterase-5 inhibitors can be very helpful in men with MS who have erectile dysfunction.^[52][53][54]

• Cognition: Some of disease modifying treatments such as interferons, natalizumab, and fingolimod seems to have a good effect on cognitive problems in MS patients. There is some evidence of the cholinesterase inhibitors (donepezil) being beneficial to MS patients with cognitive disorders.^[55][56]

• Fatigue: Drugs such as amantadine^[57][58]and pemoline ^[59][60] as well as psychological consult ^[61][62] can have a good effect on reducing fatigue in MS patients.

• Internuclear ophthalmoplegia: Potassium channel blocker, like dalfampridine, can have a good effect on axonal function and improving acular adduction.^[63] Botulinum injection into eye muscles can improve diplopia in some patients.^[64][65]

• Optic Neuritis: Intravenous treatment with methylprednisolon may have beneficial effect on visual function.^[66]

• Trigeminal Neuralgia: Some drugs such as anticonvulsants (carbamazepine^[67], phenytoin^[68], gabapentin^{[69] [70]}) seems to be useful in treatment of trigeminal neuralgia.

• Lhermitte’s Sign and Dysesthesias: These symptoms can be treated with carbamazepine, clonazepam, and amitriptyline.^[71][72][73]

• Spasticity: Some drugs such as baclofen^[74], dantrolene^[75], diazepam^[76], tizanidine^[77][78][79] and intrathecal injections of baclofen can be beneficial.^[80]

• Tremor and Ataxia: There are a list of drugs such as isoniazid^{[81][82][83][84]}, carbamazepine^[85], propranolol^[86][87][88] and gluthetimide,^[89] which we can use to reduce the tremor and ataxia in MS patients but their effectiveness is not considerable.^[90]

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