By Benjamin Segal, MD, as told to Kara
Mayer Robinson
We’ve come a long way in treating MS --
it’s been one of the biggest success stories in medicine. Over the last 20
years, there has been a revolution in drugs that change the course of the
disease, particularly relapsing-remitting multiple sclerosis (RRMS).
Back when I was in training, we had no
drugs that altered the prognosis of MS or prevented attacks. The only thing we
had were steroids. We gave them to people during serious attacks to speed
recovery. But we had nothing to lower someone’s chances of developing the
disease. We also couldn’t stop future attacks, put off disability, or make it
less serious.
Now there are more than 15 FDA-approved
drugs that do just that. They include shots you can give yourself, pills, and
intravenous infusions. But they differ in how effective they are and the side
effects they have. And we don’t have a way to predict which patient will respond
best to which drug.
The goal of MS specialists now is what
we call “no disease activity.” This means no relapses, no new lesions, and no
ongoing development of disability. For many patients, we can achieve that,
especially those with RRMS.
There have also been changes in how we
look at secondary progressive multiple sclerosis (SPMS). In the last several
years, three drugs have been approved for both RRMS and SPMS. Before that,
there were no drugs approved for SPMS, except one very potent chemotherapy that
we don’t use anymore.
We now have evidence that early
treatment, and particularly treatment with certain drugs, may delay the
conversion of RRMS to SPMS. In some cases, patients don't have gradual decline
over the course of decades.
What’s on the Horizon
Many new therapies are being studied to
advance MS treatment even more. Two important areas of study are how to promote
repair in MS and how to treat progressive MS.
Remyelination and
Repair
In people with MS, myelin is destroyed,
which causes a lot of symptoms. Researchers are looking at 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 looking at a
protective or pro-regenerative part of the immune system that we can manipulate
to protect damaged neurons and stimulate new fiber growth.
My group at the Ohio State University
just published a paper about our discovery of an immune cell that rescues
damaged nerve cells from dying. It also stimulates nerve fiber regrowth. It may
not only stop further damage of the central nervous system, but it may also
reverse damage and restore function.
Treating Secondary
Progressive MS
We’ve made progress with SPMS
medication, but there’s more to be done.
Data suggests three drugs recently
approved for SPMS are somewhat effective in a subset of younger people who
still have new inflammatory lesions. But they’re unlikely to help those who are
further along with the disease. So the quest is to find treatments for those
people.
A few pills being tested in trials show
promise. One of them suppresses the immune cells that are normally found in the
brain and spinal cord. It stops the body from activating them. In a recent
phase II trial, it slowed the progress of disability in people with inactive,
progressive MS.
Finding the Right
Treatment for Each Person
Right now, we can’t predict which
patient will respond best to which drug. But there are a lot of ongoing studies
that predict which drug will be the most effective in a given individual.
Researchers are also looking for biomarkers to develop blood tests that may
tell us if someone’s more likely to respond to one drug versus another.
Vitamin D, Antioxidants, and Gut Microbiome
Some studies show that very low levels of vitamin D raise your chances of
developing MS. Now there are studies to see if boosting vitamin D levels with
extra supplements may tamp down new attacks or new lesions for people who
already have it.
There are also studies that look at the gut microbiome and if you can manage
MS better by changing the bacteria in your gut.
It’s not conclusive yet, but researchers are looking at whether certain
antioxidants may alter treatment or management of MS. One is called lipoic
acid. A few studies suggest it may slow the loss of brain tissue in people with
MS. There will likely be future studies that look at lipoic acid and other
antioxidants in greater detail.
New Ways to Manage Symptoms
One of the most common and hard-to-manage symptoms of MS is fatigue. There
are studies on pills and cognitive rehabilitation therapy to treat it. There’s
also a lot of research into improved prosthetics and robotics to help patients
with MS to function better.
Early, Aggressive Treatment
Now that we have highly potent drugs to treat MS, there’s a debate about
whether it’s better to start early treatment with aggressive drugs or to start
with lower-potency drugs and then step up (escalate) to more potent ones.
A recent study suggests that people treated with higher-potency drugs from
the start are less likely to transition to SPMS years down the line. New
studies that compare aggressive early treatment to escalation therapy may help
us know more.
Right now, many of my patients with MS are living full lives. I've seen
people who've been relapse-free for 2 decades with no new lesions. No one would
know that they had MS.
This is a completely different situation from when I was a resident in
training. Then, most people we saw went on to need assistance devices and had
to stop working.
A cure is very difficult to predict. We’re more likely to find treatments
that help relapsing-remitting disease and maybe completely stop the progress of
the disease. A cure may take a little longer.
From: www.webmd.com
