Treatments for Multiple Sclerosis (MS)

Treatments for Multiple Sclerosis (MS)CHAPTER 5 TREATMENTAs we have a bun in the oven read previously, clinic altogethery stray syndrome may develop to seven-fold sclerosis and because there is no way of determining whether an individual will undergo to develop MS after(prenominal) having an episode of demyelination, making the decision to treat and monitor the ongoing changes very difficult.Evidence have suggested that the earlier the start of disease modifying agents in the early kind of MS the more effective they are. There are numerous studies have indicated that starting disease modifying agents after clinically isolated syndrome delays the onset of MS, but these studies mud controversial.There have been seams whether or not to start disease modifying agents after a clinically isolated syndrome. Those who support the start of these agent following(a) diagnosing of CIS cite the results of nearly clinical trials that shows that these drugs reduce the assay of developing to MS by one third. A treat all early approach have been proposed as trounce to ensure all people who would go on to developing MS do receive the discussion .The other side of this argument have existing evidence for the disease modifying agent in MS shows only modest short term effectiveness in high risk of infection cases of CIS. Treatment is unnecessary for those who would never gone on to developing MS after CIS.Four large clinical trials have been conducted to determine whether early intercession following an episode of CIS lot delay the 2nd clinical episode, and therefore the diagnosis of clinically definite MS5.1 Controlled High-Risk Subjects Avonex MS Prevention acquire (CHAMPS)The goals of the study areThe early induction interferon beta-1a (AVENOX ) treatment can delay the 2nd episode of demyelination which in turn can signal definite MSIf the treatment would have any benefits on MRI detected brain lesions.Subjects have in this study had experienced a single episo de of isolated neurological event suggesting demyelination and had multiple clinically silent MRI lesions, which they represent a high risk for a second neurological attack (definite MS) (40, 41).The results indicated that AVENOX (interferon beta-1a) had importantly delay the 2nd neurological attack, and MRI finding showed that AVENOX can decrease the volume of brain lesions and as well as fewer lesions . Based on this study, the FDA approved that patients with clinically isolated syndrome with MRI detected brain lesions to receive AVENOX .figure(2).(40)(42)Figure (2) impact of interferon beta following first neurological attack stemmahttps//quo.novartis.com/extavia/images/extavia_EFFICACY1_banner.jpg5.2 Early Treatment Of MS ( ETOMS )The goals of the study areDetermine if very low doses of interferon beta 1a (REBIF) delays the onset of clinically definite multiple sclerosis in people who experienced only one clinical event but had multiple MRI lesions (43,44).Results indicated that The group of people who received interferon beta-1a (REBIF) who real clinically definite MS (34%) is fewer than the group of people receiving placebo (45%) during the period of the study.(45)The twist of new lesions has decreased in the treatment group and the demyelination areas is significantlylower.figure(3).(45)Figure (3 ) abridgment between the groups receiving REBIF and placeboSourcehttp//dailymed.nlm.nih.gov/dailymed/archives/image.cfm?archiveid=100714type=imgname=rebif-01.jpg5.3 Betaseron In Newly Emerging MS For Initial Treatment (BENEFIT)The goals of the studyDetermine if interferon beta-1b can delay the onset of clinically definite MS in subjects with first clinical sign of MS or CIS who are at a high risk for developing MS (46).ResultsAt day 255 of the study, one quarter of the subjects in the placebo group had actual clinically definite MS. In the other hand, it took 618 days for approximately same number of subjects in the treatment group to develop clinically defi nite MS. (47)After the two years study, it was determined that 28% of the subjects under the treatment group had developed clinically definite MS compared to the 45% of the placebo group (47)The FDA has approved that patients who have experienced CIS and have MRI feature consistent with MS to receive the treatment with Betaseron figure (4).Figure (4) comparison between Betaseron receiving group and placebo groupSourcehttp//www.iodine.com/label-content/261fde67-efb2-4bd7-947e-4f68a56e76ff-c71a5c99d2acf2ddb0e66c9266460f4c.jpg5.4 The pre-CIS studyStudy goalsDetermine the period of while it takes for subjects diagnosed with clinically isolated syndrome receiving glatiramer acetate rayon ( Copaxone ) to develop a second attack that would confirm the diagnosis of definite MS.Results indicated that the group who received glatiramer acetate in comparison with the placebo group, has significantly reduced the risk of developing clinically definite MS.Based on these results, the FDA has indi cated to that individuals who have had first clinical episode and MRI feature consistent with MS to receive copaxone as treatment.Based on these trials , it have been approved the necessity of starting treatments as soon as possible for clinically isolated syndrome patients and those who have first clinical episode and MRI evidence suggestive of multiple sclerosis (48).The interferons agents should be utilize with high cautions by depressed patients or individuals with history of first gear because of some evidence indicated that these meds may progress the depression symptoms. In patients with depression the physician should give best possible treatment decision to not worsen the depression episodes and in same time have positive effects in the case of treatment purpose (49).5.5 Interferon beta medicationAvonex (interferon beta- 1a) it has been shown in the previous clinical trials to reduce the frequency of relapses in MS and the number of the new lesions on MRI, and it also red uces the disease progression. It has been also shown that Avonex reduces the risk to develop MS in clinically isolated syndrome at high risk patients.Uses CIS and relapsing forms of MS (secondary progressive MS).Dosage 30 micrograms once a week IM injection.Side effect flue-like symptoms following the injections, depressions, anemia, elevated liver-colored enzymes and liver toxicity.Betaseron (interferon beta-1b) in the previous clinical trials, betaseron has shown that it reduces the frequency and severity of relapses. In addition, it also showed that it reduces the number of new lesions or even busy lesions on MRI. Like Avonex, betaseron have also the ability to delay the onset of MS in people with CIS and has been approved by the FDA for this use specifically.(50)Uses CIS and relapsing forms of MS ( secondary progressive MS )Dosage 250 micrograms once every two days subcutaneous injectionSide effects flue like symptoms after injections, injection site reaction, depression, el evated liver enzymes and low white blood cells counts.Rebif (interferon beta-1a) has shown to reduce the frequency, relapses and the number of new / active lesions on MRI. Like avonex and betaseron, rebif has demonstrated that it can delay the onset of MS in patients with CIS. But, unfortunately it have not been approved by the FDA for this use yet. (51)Uses CIS and relapsing forms of MS ( secondary progressive MS )Dosage 20 micrograms every day subcutaneous injectionSide effects flue like symptoms after injections, injection site reaction, depression, elevated liver enzymes and low white blood cells counts.Copaxone (glatiramer acetate) in addition to interferon beta drugs, Copaxone has shown to reduce frequency of relapses and the number of new/active lesions on MRI scan. Its been used in relapsing remitting type of multiple sclerosis. Until the present, the mode of action have not been discovered. Some theories have been suggested but no scientifically proven theory is discover ed.(51)Uses CIS and relapsing remitting forms of MSDosage 44 micrograms 3 times a week subcutaneous injectionSide effects injection site reactions, a reaction after injection, anxiety, chest tightness, dyspnea and flushing.In conclusions, there is no definite treatment of multiple sclerosis or clinically isolated syndrome in the presence of demyelination of the central nerve system. But, reducing the amount of the lesions, frequency of the episodes and prolonging the period of developing MS in high risk patient is the goals we are flavor for.CIS can be difficult to diagnose or to determine whether or not to start the treatment, and the physician may find a hard time to find the best decision in these cases keeping in mind that the sooner the beginning of the treatment the less progressive the disease is (52).5.6 Prevention presumptuousness to the heterogeneous etiological factors and often idiopathic characteristic of CIS, there are no clear means of prevention exists. In postinf ectious patients with CIS, prevention of the infection is the best means of prevention. In acute disseminated encephalomyelitis, almost 70% of cases are associated with infections and 5% (approximately) with vaccination. acute disseminated encephalomyelitis rates are estimated with 1.5 per millions (2 per million) in association with live measles vaccinum compared to 1 in 1000 risk of postinfectious ADE with measles infections, suggesting that vaccines may decrease the risk of post infection complications. Unfortunately, vaccines are not available for all bacteria and viruses (53).