Management of Multiple Sclerosis

Published Online: November 25, 2013
Amy Perrin Ross, APN, MSN, CNRN, MSCN
Patients with multiple sclerosis (MS), a disease of the central nervous system that disrupts signals within the brain and also the signals between the brain and body, will likely experience symptoms that may negatively impact their quality of life (QOL). Due to the complexity of MS and its disease burden, multidisciplinary management that combines pharmacologic and nonpharmacologic strategies with patient education is necessary. Diagnosing relapses of MS in clinical practice can be difficult due to the multiple subtypes of MS, variations of symptomatology, and pseudo-relapses. Managing relapses also presents its own set of challenges, for example, evaluating if treatment is appropriate and determining which agent would be most effective for a patient if treatment is recommended. Patient education is essential for achieving optimal outcomes for patients with MS and improving patient QOL, and should increase awareness of: (1) the disease itself and its progression; (2) the signs and symptoms of MS; (3) current treatment strategies and plan of care; (4) the recognition and management of relapses; (5) the value of treatment adherence and impact of nonadherence; and (6) hope for the future. The management of active MS may be further complicated by the complex variety of pharmacotherapeutic options, and in some instances, by having to switch between agents and drug classes. Newer agents in development (eg, alemtuzumab, ocrelizumab, laquinimod) offer the opportunity to expand the therapeutic armamentarium, although further long-term data are required to evaluate any safety concerns associated with newer agents.

(Am J Manag Care. 2013;19(16):S301-S306)
According to the National Multiple Sclerosis Society, multiple sclerosis (MS) is a disease of the central nervous system (CNS) that disrupts signals within the brain and also the signals between the brain and the body.1,2 Due to the CNS pathophysiology that characterizes MS, individuals afflicted by the disease will likely experience symptoms that range from numbness and tingling to blindness and paralysis.3 Although MS itself is not typically fatal, the neurological disease is incurable and can have a profoundly negative impact on patient quality of life (QOL).4-6 Fortunately, MS is now a treatable condition and many new pharmacotherapies have entered the market in recent years, with additional agents currently in late-stage development.

MS is a complex disease with various symptoms that impact many human functions. As such, a multidisciplinary approach that combines pharmacologic and nonpharmacologic management, patient education strategies designed to minimize adverse effects of medications (Table) and to increase treatment adherence, patient support groups, and an emphasis on maintaining open and effective lines of communication between the patients and healthcare professionals is essential.7,8 According to Ross, every patient with MS should have a primary care physician and a neurologist in the multidisciplinary team to oversee their care. Nurses are also important members of this team, as patients with MS frequently look to their nurses for additional information regarding the disease and their care. The nurse is the facilitator for patient autonomy, teaching self-directed learning techniques and empowering patients to take responsibility for the treatment of their disease. In addition, the management of primary, secondary, and tertiary symptoms of MS may involve specialists from many areas, such as physical therapists, psychologists/ neuropsychologists, occupational therapists, urologists/neurourologists, and vocational rehabilitation counselors (Figure 1).

Assessment and Management of Relapse

Relapsing-remitting multiple sclerosis (RRMS) is the most common subtype of MS, accounting for 85% of MS cases at initial diagnosis. Patients with RRMS will experience relapses (also called attacks, exacerbations, or flare-ups) separated by periods of full or partial recovery.1,9 According to the 2010 revision of the McDonald criteria for the diagnosis of MS, relapses are defined as “patient-reported or objectively observed events that are typical of an acute inflammatory demyelinating event in the CNS, current or historical, with a duration of at least 24 hours, in the absence of fever or infection.”10 Furthermore, paroxysmal symptoms, historical or current, may also be considered relapses if they consist of multiple episodes that occur over a minimum of 24 hours.10 The potential signs and symptoms of relapse are numerous and will vary in presentation depending upon the location of the demyelinating event and inflammation.2 Any disability that results from a relapse of MS can persist for several weeks or for months,11 although recovery time may be hastened through pharmacologic intervention.12

The diagnosis and treatment of MS relapses in clinical practice is challenging, as there are multiple manifestations of relapse, such as optic neuritis, paroxysms, and myelitis, and symptoms of relapse can vary even within each particular manifestation.13 Adding further complication to the treatment of relapses is the common misconception among many patients that disease remission is a symptom-free period, even though most individuals will always be symptomatic in some form.14 While fluctuations in symptoms, such as fatigue, may be caused by factors as common as stress or sleep deprivation, and may be mistaken for a relapse in MS,14 pseudo-relapses and infections can also make the diagnosis of an actual relapse more difficult. For instance, the transient worsening of symptoms due to overexposure to heat or overexertion are not representative of actual relapses of MS, but are most likely attributable to conduction blocks within demyelinated axons.14 Infections such as viral upper respiratory infections and simple urinary tract infections are often associated with pseudo-relapses in patients with MS14; however, systemic infections may provoke actual relapses by introducing a proinflammatory bias in immune responsiveness that is capable of triggering disease activity and exacerbations.15

If a true clinical relapse is suspected in a patient with MS, the clinician must decide if the relapse is to be treated at all, and if so, which treatment should be selected. Investigators have studied the effects of corticosteroids on both short- and long-term recovery from optic neuritis in patients with MS, and the results have demonstrated significant improvements in short-term outcomes; however, no long-term benefits in terms of attaining pre-relapse functioning have been observed.16-18 Therefore, the decision to treat a relapse in MS often depends on the functional impact that the relapse may have on the patient’s daily life. Typically, the standard of care and first-line treatment option for relapses in MS is 3 to 5 days of intravenous methylprednisolone (500-1000 mg/d), with or without an oral taper, or a high-dose oral steroid.14 Because high-dose oral and intravenous steroid regimens have shown similar efficacy in treating MS relapses,19,20 the decision of which agent to use is normally determined by patient and clinician preferences. Other treatments for relapses of MS include adrenocorticotrophic hormone, intravenous immunoglobulin, and plasma exchange; however, these treatments are usually reserved for those who are unresponsive to first-line therapies.14 It is important to note that combining comprehensive rehabilitation with standard, intravenous methylprednisolone therapy may result in improved performance on measures of disability and QOL over a 3-month period following a relapse in patients with MS.21

Patient Education

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