Multiple sclerosis – better treatments for better control
WITH newer treatments, multiple sclerosis, a potentially debilitating disease, can be controlled.
Multiple sclerosis is a chronic illness, another disorder of the nervous system that occurs when the immune system mistakenly attacks different areas of the brain or spinal cord, specifically the fatty material encasing nerves known as myelin.
Sadly, these attacks can lead to a range of crippling outcomes, including blindness and physical disability. What causes the disease currently remains a mystery.
In Singapore, multiple sclerosis is much more rarely encountered compared to the West, said Associate Professor Kevin Tan, Senior Consultant, National Neuroscience Institute (NNI). He estimates that about 200 people here are affected.
Some theories for why the disease is more common in temperate countries include genetic factors and potential environmental infections. “A well described phenomenon is the further away you are from the equator, the higher the rate of multiple sclerosis,” he said. Symptoms can appear suddenly
Depending on which part of the nervous system is attacked, symptoms can range from weakness, numbness, unsteadiness, inability to control bladder or bowel functions, and vision problems, said Prof Tan.
During an attack, symptoms can develop over days or weeks. They tend to vary from person to person, and between attacks in the same person. The disabilities may appear similar to those of ageing, although most patients are far from elderly. The first symptoms commonly emerge between ages 15 and 50, and proportionately more women than men get the illness, he said.
As symptoms occur acutely, people with multiple sclerosis may end up going to the emergency department. Attacks may vary in severity and how quickly the symptoms progress. Attacks should not be ignored, as they can be treated and symptoms reversed. Unfortunately, with some severe attacks, patients may end up bedridden or wheelchairbound.
Prof Tan said doctors still do not understand how the disease develops. “But we know what happens when it is active – the immune system attacks the nerves. How it becomes active is still being worked out.”
Stressful situations may sometimes trigger an attack, but that does not mean it is a cause of the disease, he said. “You must have had the condition to begin with. The current thinking is that these people have some genetic predisposition to developing multiple sclerosis, but something in the environment still needs to trigger the immune system and cause it to go out of control.” Diagnosis can be tricky
Because there are other medical conditions that have similar symptoms as that of multiple sclerosis, doctors will need to exclude these conditions before making a diagnosis.
“This is not based on a single test, but rather on the combination of symptoms that are typical (such as losing vision, unsteadiness and loss of bladder or bowel function), detection of nervous system dysfunction through physical examination, and areas of damage on MRI [magnetic resonance imaging] scan,” said Prof Tan.
Areas commonly affected include:
• The optic nerve (which controls vision).
• The brainstem (the area at the back of the brain that controls vital functions).
• The cerebellum (which controls balance and coordination).
• The spinal cord. Disorders of the spinal cord can cause weakness, numbness, as well as bladder and bowel control problems. Another test useful for diagnosis is a lumbar puncture, which can show the presence of the immune system activation in the brain. This is a procedure where a needle is used to draw cerebrospinal fluid from the lower back. Treat early to stop progression With new and better disease-modifying treatments developed over the years, multiple sclerosis can now be more effectively controlled. Treatments should not be delayed because early control of the condition can lead to better outcomes in the long term.
The moment the disease is diagnosed, doctors will discuss treatment options with patients. “If patients respond well to treatment, potentially they will be able to lead normal lives. Some do so well that other people won’t even suspect they have the disease.”
Prof Tan said although lifestyle changes such as regular exercise, a healthy diet and a positive state of mind are important and beneficial for patients, they cannot replace disease modifying treatments.
“These treatments control the disease through different mechanisms and effects on the immune system, leading to prevention of further attacks.”
However, some of the more aggressive treatments can suppress the immune system and put patients at higher risk of infections.
“Other treatments modulate rather than suppress the immune system, changing it from one that is active to one that is less likely to attack itself.”
Other treatments may be required for symptom relief of those related to bladder dysfunction, numbness or muscle stiffness. Treatment of multiple sclerosis is complex because the disease affects patients in many ways. There is no single treatment to treat everything. “Multiple strategies are needed to address different aspects of the disease,” said Prof Tan.
Multiple sclerosis is a chronic illness, another disorder of the nervous system that occurs when the immune system mistakenly attacks different areas of the brain or spinal cord, specifically the fatty material encasing nerves known as myelin. These attacks can lead to a range of crippling outcomes, including blindness and physical disability.
• This story was first published in Singapore Health, Nov - Dec 2018 issue.