Multiple Sclerosis: Symptomatic Treatment
Bever Jr CT
Curr Treat Options Neurol 1999 Jul;1(3):221-238
The Maryland Center for Multiple Sclerosis,
Univ of Maryland, Dept of Neurology, and
Neurology and Research Services, VAMHCS, 22 South Greene St., Baltimore, MD 21201, USA
Therapy for Multiple Sclerosis (MS) that prevents exacerbation of the disease and slows the progression of disability has not diminished the importance of treating symptoms.
Because the new agents are not curative and rarely reverse existing deficits, many patients under treatment have or will have persistent symptoms.
Many Neurologic symptoms are seen in patients with MS, but it is important to recognize that some NonNeurologic symptoms, such as Pain, Fatigue, and Mood Disturbance, are common and may cause significant disability.
The first and most important step in the management of symptoms is to discuss the symptoms with the patient on an ongoing basis.
The second step is to recognize treatable symptoms and to apply the appropriate strategies for management.
There have been promising results with experimental agents, primarily Potassium Channel Blockers, that may improve function in DeMyelinated fiber pathways and that offer the possibility of treatment for a range of symptoms.
At present, the management of symptoms varies, depending on the symptom, and it involves the coordinated application of a range of treatment approaches including medication, lifestyle changes, rehabilitation, and, in some cases, surgery.
Multiple Sclerosis: ImmunoTherapy
Bielekova B, Martin R
Curr Treat Options Neurol 1999 Jul;1(3):201-220
National Institutes of Health, National Institute of Neurological Disorders and Stroke, Cellular Immunology Section, NeuroImmunology Branch, Building 10, Room 5B-16, 10 Center Drive MSC 1400, Bethesda, MD 20892, USA
Given our current knowledge, there is a need for the early institution of ImmunoModulatory therapy, especially for patients with poor prognostic factors (Motor and Cerebellar Symptoms, frequent disease exacerbations, and a high level of activity on Magnetic Resonance Imaging ).
Patients who progress despite ImmunoModulatory therapy should be reevaluated in terms of diagnosis, development of Neutralizing AntiBodies, or compliance.
If a patient has a partial response to ImmunoModulatory therapy but his or her disease, as assessed by clinical and MRI criteria, remains very active, every effort should be made to modify disease progression by searching for an ImmunoSuppressive therapy regimen before irreversible and considerable disability has accumulated.
For the majority of patients, Multiple Sclerosis (MS) is a chronic condition.
Therefore, until a curative treatment has been developed, the available repertoire of ImmunoSuppressive or ImmunoModulatory treatments should be assessed with respect to the possibility of long-term use.
This is particularly important for new ImmunoSuppressive drugs, such as Cladribine or Mitoxantrone, or for invasive procedures, such as total Lymphoid irradiation or autologous Bone Marrow Transplantation.
For the latter treatments, experience with long-term administration is not available or the potential side effects (eg, CardioToxicity with Mitoxantrone) limit the cumulative dose.
These considerations may limit long-term administration and thus the general usefulness of some drugs. Even with proven efficacy, we need to define the next step once treatment has to be discontinued.
We should also address whether exacerbating disease by discontinuing an effective therapy is a potential hazard. What other therapeutic options remain once the current treatment is discontinued?
Answers are not readily available at the moment, but the question should influence our decisions in the selection of traditional, well-studied or new, potentially promising therapies.
Curr Treat Options Neurol 1999 Mar;1(1):68-73
Rabin Medical Center, Division of Neuro-Ophthalmology, Depts of Neurology and Ophthalmology, Petach Tikva 49100, Israel
Patients with acquired forms of Nystagmus may suffer from Oscillopsia and Blurred Vision; abolishing or reducing Nystagmus ameliorates these symptoms.
Ideally, treatment of Nystagmus should be directed against the PathoPhysiologic mechanism responsible.
Identification of Nystagmus pattern is important in directing therapy and occasionally requires electronic eye movement recording for precise characterization.
Patients with acquired Pendular Nystagmus, particularly those with Multiple Sclerosis, often benefit from Gabapentin, a drug with few side effects.
Scopolamine, Clonazepam, and Valproate are also useful in some patients. A new drug, Memantine, was effective in treating Pendular Nystagmus in one study, but it has not yet been approved for use in the United States.
Periodic alternating Nystagmus usually responds to Baclofen. Central Vestibular Nystagmus, including downbeating and upbeating forms, can be treated with Baclofen or Clonazepam.
In some patients, treatment of an underlying condition, such as Periodic Ataxia, Whipple's Disease, and Chiari Malformation, abolishes Nystagmus and improves vision. If pharmacologic therapy fails, Optical devices can be considered in selected patients.
Injections of Botulinum Toxin and surgery to weaken ExtraOcular muscles are prone to induce Diplopia and may precipitate plastic-adaptive Ocular Motor changes that eventually negate the beneficial effect.