Multiple Sclerosis Early Intervention Can Mean a Bright Future

Nearly a million Americans—about one in 300—have multiple sclerosis (MS), an autoimmune disease affecting the spine, brain and optic nerves. Its cause is uncertain, but we do know that—like in other autoimmune diseases—an unknown trigger turns the patient’s immune system against itself, causing inflammation of the brain and spinal cord. Plaques or lesions are left behind, a form of scarring known medically as sclerosis. MS causes many such scars, hence the name “multiple sclerosis.”

Although there is no one definitive test for MS, this scarring appears as spots on an MRI in areas where myelin is damaged. Like insulation on an electrical wire, myelin is a coating that protects and isolates nerve tissue. Damage to myelin causes a wide range of symptoms in MS, the most common being fatigue, difficulty walking, numbness, tingling, weakness, dizziness, vision changes, mood changes and bladder problems.

Just a few decades ago, medical science had no tools to treat MS. But that has changed dramatically. Today, we have over 20 different therapies, with new agents approved each year.

Risk Factors

MS is an autoimmune disease, like type 1 diabetes, psoriasis and rheumatoid arthritis. Although it is more common in certain populations, it can strike anyone.

Some risk factors that may encourage the disease:

• It is more prevalent among women, who are about three times more likely to be diagnosed than men. We don’t know exactly why, but hormonal differences may play a role.
• Risk is higher for people who have an immediate family member with MS, making genetics a contributing factor.
• MS is more prevalent farther from the equator. We know vitamin D deficiency is a risk factor, so it’s likely that the additional exposure to the sun at lower latitudes is protective, since sunlight stimulates vitamin D production in the body.
• We suspect that childhood and adolescent obesity increases risk.
• Smoking both increases the risk of developing MS and can significantly worsen the disease in people who have MS. I encourage all my MS patients to quit.

There is some evidence that African Americans are likeliest to exhibit more severe symptoms once diagnosed, but MS affects all races and ethnicities.

No Two Cases Are Alike

MS symptom severity is highly variable. Some patients have frequent severe early relapses, but in others, symptom progression is slow, starting as early as the teen years. When symptoms eventually spur the patient to seek medical help, we often find that early symptoms were either overlooked or misdiagnosed.

Diagnosis, which typically occurs between the ages of 20 and 50, can be challenging, as many of the signs of MS can be caused by other conditions. For example, carpal tunnel syndrome or a pinched nerve can cause numbness and tingling in the extremities. Transient neurological symptoms are unlikely to be due to MS, but it’s a red flag if symptoms last longer than 24 hours.

Accurate diagnosis calls for detective work—careful consideration of the patient’s history, exam findings and tests including MRI imaging. Occasionally we find that an MS diagnosis is incorrect. Sometimes patients with migraine are misdiagnosed as having MS, as migraine can cause similar abnormalities on an MRI. Even experienced neurologists may have difficulty confirming a diagnosis and will refer the patient to a neurologist with a specialty in MS.

Generally, we see patients in MS clinics who had a concerning MRI result and were referred by their internist or general neurologist. We conduct a detailed history and thorough neurologic examination. If we remain suspicious, we order an MRI of the brain and spinal cord.

Sometimes diagnosis is immediate—confirming or excluding MS on the patient’s first visit. But in many cases, watchful waiting is the right course of action. We follow the patient closely to see how symptoms evolve over months and may need to repeat MRIs.

Emotional Effects

Because anxiety and depression are so common in MS patients, we now believe they are physiologically linked to the inflammation the disease causes, rather than an emotional by-product of it. MS neurologists are familiar with the treatment of these conditions, but we also work closely with our experts in psychiatry, psychology and social work to design a blend of counseling and medical therapy to improve mood symptoms.

MS can likewise have a profound impact on family and caregivers. The disease often strikes those in the prime of life, active in careers and raising families, so it can be a jarring and confusing diagnosis when symptoms are subtle or not outwardly apparent.

We provide counseling to help patients and families understand the disease and how best to manage its effect on their lives. This is especially important when there are invisible symptoms of MS, such as cognitive problems, bladder dysfunction or depression.

The Therapy Era

Broadly speaking, MS comes in two forms: relapsing and progressive. But because it can vary in how it presents, we see a lot of overlap.

• With relapsing MS, episodes of worsening symptoms tend to occur over days or weeks, followed by eventual improvement.
• With progressive MS, there is a slow worsening over time, even without relapses.
• One form can evolve into the other—typically, the relapsing form changes over years to a progressive phase.

A generation ago, MS was a frightening and debilitating diagnosis. We could not prevent disability from MS, and we managed the symptoms as best we could. But now, this disease is highly manageable, thanks to dramatic advances in therapy. When caught early, we can treat MS before a patient experiences life-altering disability.

About 30 years ago, injectable agents were introduced and administered under the skin similar to insulin for diabetics. In the 2000s, oral medications became available. Today’s patient may also receive infusion therapy at an infusion center every month, or every six months, depending on the medication. Medications have been documented as very effective, particularly against the relapsing form of the disease.

Because MS looks and behaves differently in each patient, we tailor therapies to both the disease and any other underlying conditions. Our strategy can change as the disease evolves and more treatments become available, so it’s not unusual for the patient to take different medications over the course of their lifetime. Monitoring the drugs’ effect on the immune system is also important to avoid complications like infections. With proper monitoring, the drugs are well tolerated and safe, can slow or stop the progress and can give the brain a chance to heal to improve function.

The MedStar Difference

At MedStar Washington Hospital Center, we treat MS holistically, leveraging the expertise of a wide range of specialists to manage the disease and maintain the highest possible quality of life for each patient.

MS patients are managed primarily by a neurologist. Neuro-radiologists help interpret MRI scans to monitor for changes. Physical therapists, occupational therapists and physiatrists are on board to help with maintaining and regaining physical function. We frequently also work with urologists who understand the potential bladder complications of MS. Mental health experts such as psychiatrists and counselors help manage anxiety and depression. The team also includes experts in our Neurosciences Center who work with insurance companies on any necessary medication approvals.

And as a partner with the Multiple Sclerosis and Neuroimmunology Center at MedStar Georgetown University Hospital, our patients have access to ongoing clinical trials for investigational therapies.

A Bright Future

The most common misconception is that MS is difficult to treat. That reputation goes back to the days when no treatments were available. The landscape is much different now.

With MS therapies, we treat the “future you.” Not every deficit can be reversed, but our game plan is always long term and almost all symptoms of MS can be improved with careful treatment. Our goal is to make this illness manageable and for our patients to live full and productive lives.

As with many other diseases, early intervention provides the best chance at successful management. Your long-term health is at stake, so don’t ignore any chronic issues that could be symptoms of this disease.

Today’s drugs target the inflammation MS causes. But medical research is also seeking to develop agents that target the disease itself, or a cure through prevention. When we’re able to positively identify the trigger that knocks the immune system off track, we will potentially be able to stop this disease before it starts. Future therapies could also reverse the damage it causes.

I’m optimistic we’ll see such developments in our lifetime.