Multiple Sclerosis

Description

Treating the Complications

Fatigue

Fatigue affects at least two thirds of patients. It is among the most disabling problems in MS and is difficult to treat. Treating any problem (e.g., depression, hypothyroidism) that may be causing fatigue is important. Aerobic exercise programs scheduled early in the day have been helpful for patients who can participate. Preventing overheating can improve fatigue. (One study reported that cooling suit may be useful.) Modafinil (Provigil, Alertec) is a promising drug that promotes long-lasting wakefulness and is currently used in narcolepsy. Small studies are reporting that it is effective in reducing fatigue and sleepiness, with lower doses (200 mg) being more effective than higher ones. Studies also suggest that amantadine (Symmetrel) may also be helpful. Prokarin, an investigative agent, employs a skin patch containing caffeine and histamine. In one small study it improved fatigue in about half of patients. More studies are needed.

Spasticity and Lower-Limb Pain

Managing pain and spasticity in the lower limbs can be difficult. Although many drugs are used to reduce spasticity and lower-limb pain, most studies investigating these agents have been poorly designed and no treatment has emerged as a front-runner.

Exercise. Mild spasticity actually helps improve muscle tone in the legs, which is important in supporting the patients weight when walking. This benefit can be lost with drug treatment. Mild spasticity, then, should be treated with exercises several times a day that improve range of motion.

Drugs Used for Spasticity.

• Baclofen (Lioresal) has long been the drug of choice to alleviate more severe spasticity. It is available both orally and administered using an implanted pump, which seems to have helped dramatically in improving many cases of spasticity. Distressing side effects include confusion, drowsiness, and a rubbery-like sensation in the legs that makes it hard to stand.
• Antiseizure medications, such as gabapentin (Neurontin) or levetiracetam (Keppra) may help reduce spasticity without increasing fatigue or impairing concentration. Studies on gabapentin also suggested that it also have other specific benefits for MS patients, including reducing facial pain and improving vision.
• Tizanidine (Zanaflex) is an oral agent that works after one week. In one study, 75% of patients taking tizanidine reported improvement without the leg-muscle weakness experienced using baclofen. The drug does not appear to be any more effective than baclofen, however. Side effects include dizziness, drowsiness, dry mouth, and fatigue. Liver function must be monitored.
• Diazepam (Valium) is also used for spasticity and may be particularly useful for patients who also experience anxiety. Drug dependence is the primary problem with diazepam, as well as dizziness, drowsiness, and confusion. The medication should not be used by people who are seriously depressed.
• Botulinum toxin (Dysport) injections are being investigated for spasticity in specific regions. A 2000 study, for example, reported that it was helpful in reducing hip spasticity in up to two thirds of patients. It had no major side effects.
• Dantrolene (Dantrium) is an effective alternative for MS patients who cannot tolerate diazepam or baclofen. Because dantrolene causes muscle weakness, however, it is best suited for two opposite types of patients, either those who are wheelchair bound but still suffer from spasticity, or for those whose muscles are still strong, so that the drug-induced weakness isn't unduly debilitating. It also causes nausea, vomiting, and anorexia, and with high dosages it can cause dangerous liver damage.

Surgery. In very severe cases where medication and exercise are not helpful, surgery should be considered. In such cases, the surgeon cuts the tendons that are involved with spasticity.

Spinal Injections. In very severe cases, administering phenol using spinal injections in the lower back may reduce pain and spasms for some patients with severe conditions. Most patients are not appropriate candidates for this approach.

Bladder Dysfunction

Treating Urge Incontinence. Urge incontinence (the need to urinary frequently) is common in MS patients. To help reduce social difficulties, patients should not drink fluids before going to places where restrooms are not easily available. When possible, they should urinate every three to four hours. A number of medications are available for urge incontinence, including anticholinergic drugs, such as propantheline bromine (Pro-Banthine), tolterodine (Detrol), or oxybutynin (Ditropan). Sacral nerve stimulation (InterStim) sends electrical pulses to help retrain nerves in the pelvic area, and is also proving to be helpful. Botulinum toxin injection into the urinary tract muscles is being investigated and may be helpful for incontinence caused by spasticity. [See Well-Connected Report #50, Urinary Incontinence.]

Treating Urinary Retention. Urinary retention occurs in some patients. Sometimes urination can be stimulated simply by pressing the bladder area with the fist or hand, by tapping against it, or by straining. Drugs being tried with some success for this problem are desmopressin (DDAVP), ordinarily used for bed wetting in children, and maprotiline (Ludiomill), an antidepressant. If medication is ineffective, a catheter may be needed, either one used intermittently by the patient or placed in the urinary tract. Various new surgical procedures that reconstruct the bladder or divert urine flow may be effective in severe cases of bladder dysfunction. It should be noted that because urinary symptoms usually remain intermittent for years, treatment approaches for bladder dysfunction should be limited to medications and other reversible therapies as long as possible.

Treating Urinary Tract Infections. Urinary tract infection is common in MS patients and a urinalysis should be performed with any symptom flare-ups, any fever, or any change in bladder symptoms. Treatment uses appropriate antibiotic regimens. To help prevent infections, patients should drink plenty of cranberry juice. [See Well-Connected Report #36, Urinary Tract Infection.]

Bowel Dysfunction

In addition to maintaining a high-fiber diet and drinking plenty of fluids, bulk agents such as psyllium (Metamucil), with or without a stool softener, may be needed. Going to the bathroom the same time every day, particularly after a meal and waiting there for a movement, reduces the risk of losing control later in the day. (Patients can use this time to read, make calls, or write). Exercise helps patients avoid becoming dependent on laxatives, enemas, or colonic irrigation, which can eventually slow down the bowel and cause imbalances in electrolytes. Biofeedback techniques may be helpful in some patients with limited multiple sclerosis. Other approaches being investigated include enemas administered through catheters or abdominal incisions.

Tremors

Major tremors can be very distressing and are particularly hard to treat. Carbamazepine and glutethimide have some possible benefits, but in general drug therapy has been disappointing. Weight applied to the affected limb has been beneficial in about 20% of cases. Surgery is very controversial.

Facial Pain

Facial Pain. Trigeminal neuralgia is severe facial pain, usually on one side, that can be very severe and may be triggered by an event as mild as a breeze or teeth brushing. If nonprescription painkillers fail to alleviate facial pain, it can be treated with anticonvulsive medications. Carbamazepine (Tegretol) is currently the drug of choice. (Carbamazepine is also effective on other types of MS pain and spasm-related symptoms, including itching and aching.) Another antiseizure drug, gabapentin (Neurontin), however, may be particularly effective for MS. (This agent also appears to improve blurred vision associated with MS and may help spasticity in general.) Other drugs used for this symptom include phenytoin (Dilantin), diazepam (Valium), or pimozide (Orap), and the antidepressant amitriptyline (Elavil). If severe pain persists and interferes with function, some patients elect to have a section of a nerve surgically removed or blocked. This relieves pain but causes numbness. Before patients commit to such a procedure, they should ask the doctor to temporarily block the nerve with an anesthetic in order to experience the effect of numbness before undergoing irreversible surgery.

Sexual Dysfunction

Sildenafil (Viagra) is proving to be helpful for improving sexual dysfunction in some MS patients. Corticosteroids, which are sometimes used for other MS symptoms, also improve sexual function. Other treatments are available that might be very beneficial. Patients should not be shy about discussing sexuality with their physician. [See Well-Connected Report # 15, Impotence.]

Difficulty Swallowing

Techniques for helping patients with swallowing problems include using specific head and tongue positions to assist swallowing, and preparing pureed food. Patients may need to work with otolaryngologists (physicians specializing in ear, nose, and throat disorders) to address swallowing problems. Left untreated, swallowing problems can increase MS patients' risks of aspiration pneumonia, malnutrition, dehydration, and other problems.

Osteoporosis

In addition to calcium and vitamin D supplements, a number of agents are now available to help prevent bone loss and reduce the risk of fractures due to osteoporosis. [For more information, seeWell-Connected Report #18 Osteoporosis.]

Treating Depression and Managing Stress

Treating Depression. Treating depression may not only improve mood but may also have direct benefits for MS patients.

• Antidepressants known as tricyclics may have specific benefits for MS in addition to managing severe depression. Amitriptyline (Elavil), for example, may be effective in alleviating the extreme mood swings that frequently occur in MS patients. This emotional incontinence, the inability to control emotions, can distress some patients more than physical symptoms. Other tricyclics include desipramine (Norpramin, Pertofrane) and imipramine (Tofranil), which have additional effects that improve bladder symptoms in some patients. These drugs, however, can have severe side effects.
• The newer drugs, known as SSRIs (serotonin-reuptake inhibitors), which include fluoxetine (Prozac), sertraline (Zoloft), and paroxetine (Paxil), may be better tolerated. A study on sertraline further suggested that it may also reduce the immune system's inflammatory response.

Stress Reduction and Supportive Measures. Stress can worsen symptoms, and may worsen the disease itself. Reducing stress is an important part of general health maintenance. Studies on methods for reducing stress report improved well-being in MS patients. A sense of control and connection appears to be extremely important for MS patients. Relaxation or meditation exercises can be beneficial, although cognitive-behavioral methods may be more effective in these patients. One interesting 2002 study reported fewer stress-related brain lesions in patients who reduced stress using cognitive-behavioral methods for learning how to cope. It is not clear if this small study has widespread significance, however. [See Well-Connected Report # 31 Stress.]

Support for the Caregivers. Many MS patients require long-term physical, financial, and psychological support from family and friends. Both the physical and mental health of the caregiver are critical. The burden may be considerable and threaten both. In fact, the more hours dedicated to the MS patient, the more depressed the caregiver is likely to be. This leads to a cycle of poor caregiving followed by reduced functioning in the patient. In one study, caregivers reported that among the most distressing aspects were the psychological impact of MS on the patient and the incurability of the disease. Most caregivers identified the best form of support to be practical help, cooking, cleaning, and better availability of medical and financial advice. Therapeutic help for family members may also be helpful.

Improving Mental Functioning

Interferon, used to treat MS, may improve mental function. Other medications and therapies may also be helpful. For example, agents called cholinesterase inhibitors, such as donepezil (Aricept), may help improve mental functioning. Vocational programs for the patient may also be helpful. Therapeutic programs for both patients and their families can help them better understand and cope with cognitive weaknesses, such concentration and problem solving.