Until the 1980’s Neurology was frequently labeled “the specialty of diagnosing untreatable diseases”. Until the early 1990’s Multiple Sclerosis (MS) remained in that category. Prior to the advent of MRI, we could only diagnose the most severe cases. Prior to treatments being available, labeling a person with MS was frequently, deliberately avoided. Now that we can offer a variety of treatments, everything has changed for the better.
The basic cause of MS is unknown. We do know that something triggers the immune system to create cells that normally fight infection, but attack cells in the brain and spinal cord instead. These cells migrate into the central nervous system from the blood stream in random places and at random times for no apparent reason. Treatments are aimed at modifying or blocking the activity of these cells.
As experience with sophisticated imaging and other diagnostic testing grew, neurologists realized that in the prior years, only diagnosing the worst cases, we were seeing one extreme end of the “bell shaped curve”. We now know there are many people with mild or moderate forms of MS. In some cases, so mild, it can be an elusive diagnosis. Even so, every person found to have MS should be receiving some form of treatment aimed at reducing their risk of progression of the disease. With all of the available treatments, it is unusual to not find one suitable for each person. Here at the Palm Beach Neurological Center we try to customize treatment based on the clinical presentation of the illness as well as individual patient needs.
The earliest disease modifying treatments (DMT’s) were copolymer acetate and the interferons. They are all injectables with different dosing schedules. Their mechanisms of action in diminishing disease activity are different and each treatment carries different potential side effects. In general, however, most are safe, well tolerated, and modestly effective. Home education in self injection is provided and it is fairly simple to learn. It is similar to a person with diabetes learning to use insulin. Most newly diagnosed patients will receive one of these treatments. In general they offer about a one third reduction in risk of a person’s Multiple Sclerosis getting worse.
In addition, several years ago a more potent agent became available, natalizumab (Tysabri).We have been part of its unique administration program since it was approved. This agent may be as much as twice as effective as the above in risk reduction, but may be almost too effective. It prevents migration of immune cells into the brain. This could lead to a very serious infection in rare cases. Fortunately, we can test for the presence of the virus that causes this infection. Research is ongoing to determine if people who do not test positive for the presence of this dormant virus are at risk or not. This treatment is administered intravenously once every four weeks. We are pleased to offer this in our comfortable offices with close monitoring and supervision. Most of our patients have actually come to enjoy their monthly two hour visits! Not every person with Multiple Sclerosis is a candidate for Tysabri, so we try to carefully select patients who will benefit most with the least risk.
Another new agent in capsule form, given by mouth once a day has also been recently FDA approved. Fingolamide also seems to be more effective than the earliest agents, but carries its own set of potential side effects. The initial screening process is somewhat tedious, but for the right patient is worthwhile. It has not been out long enough for us to have extensive long term experience, so careful patient selection is important.
The last few decades have been an exciting time in neurology, with tremendous advancements in diagnosis and treatment of many conditions. Multiple Sclerosis is a prime example of the progress we have made. Newer, safer and more effective treatments are not that far away. The doctors of the Palm Beach Neurological Center are proud to offer the latest in diagnostic and treatment options for all patients with MS and other neurological conditions.