Secondary Progressive Multiple Sclerosis Management
Secondary Progressive Multiple Sclerosis Management
What are the options for treating secondary progressive multiple sclerosis (SPMS)? A 52-year-old woman has a severe case of SPMS and is about an 8 on the Expanded Disability Status Scale (EDSS). She has been on multiple interferon beta-1a medications, including Rebif® and Avonex®, without success. What course of treatment could be recommended at this point?
To know the options available for treating secondary progressive multiple sclerosis (SPMS), it is essential to understand SPMS. About 80% of people with multiple sclerosis (MS) begin their journey with fluctuations of their symptoms and disabilities. This is called relapsing MS. Many believe that the relapses are caused by inflammation within the brain and spinal cord as the immune system attacks the nervous system. If left untreated, more than half of these patients will develop a more progressive course of MS with fewer fluctuations. This is termed SPMS. SPMS is thought to represent a more degenerative phase of MS with less inflammation. This distinction is important because many believe that the drugs approved for MS work best on the inflammatory phase as opposed to the degenerative phase.
In this particular case, the patient has an Expanded Disability Status Scale (EDSS) score of 8. The EDSS was developed by John Kurtzke, MD, in 1983 to follow disability over time. This scale of 0 (normal) to 10 (passed away) is not linear, and patients do not move up the scale in a regular fashion. A patient scoring an 8 is not ambulatory and cannot transfer without a lot of assistance. Thus, this person has considerable disability. To date, no pharmacologic treatment is available that restores ability. In a situation such as this, the assumption is that little inflammation is going on in the nervous system; thus, and not surprisingly, the routine MS treatments do not work well.
Almost all patients with progressive MS stop progressing at some point. Obviously, we would like to stop the progression earlier rather than later, but without treatment, progression usually still halts at some point. It is rare to die from MS, but rather, people die with MS.
Treating MS in general is about (1) disease management, (2) symptom management, and (3) person management. If new symptoms and findings occur with progression in between attacks, the use of interferon, glatiramer acetate, or natalizumab is indicated. Mitoxantrone may be indicated for those who continue to progress despite these treatments. Mitoxantrone has risks; thus, the risk/benefit ratio must be evaluated.
At an EDSS score of 8, a rigorous approach toward symptom management is necessary with an emphasis on maintaining function despite the progression. This means regular physical and occupational therapy. Speech therapy may be necessary for swallowing, speech, and cognition. A properly fitting, independently powered wheelchair is essential to maintaining mobility in disability.
The patient needs to be evaluated for psychological, personal, and vocational needs with a plan of care in that arena formulated. Patients have a tendency to withdraw from society. Remaining mobile and active is important to prevent the cognitive dysfunction that results from this isolation.
I truly believe that there are treatments for SPMS, but they require a team approach and rely less on disease management and more on symptom and person management.
Question
What are the options for treating secondary progressive multiple sclerosis (SPMS)? A 52-year-old woman has a severe case of SPMS and is about an 8 on the Expanded Disability Status Scale (EDSS). She has been on multiple interferon beta-1a medications, including Rebif® and Avonex®, without success. What course of treatment could be recommended at this point?
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Response from Randall T. Schapiro, MD Clinical Professor of Neurology, University of Minnesota, Minneapolis, Minnesota |
To know the options available for treating secondary progressive multiple sclerosis (SPMS), it is essential to understand SPMS. About 80% of people with multiple sclerosis (MS) begin their journey with fluctuations of their symptoms and disabilities. This is called relapsing MS. Many believe that the relapses are caused by inflammation within the brain and spinal cord as the immune system attacks the nervous system. If left untreated, more than half of these patients will develop a more progressive course of MS with fewer fluctuations. This is termed SPMS. SPMS is thought to represent a more degenerative phase of MS with less inflammation. This distinction is important because many believe that the drugs approved for MS work best on the inflammatory phase as opposed to the degenerative phase.
In this particular case, the patient has an Expanded Disability Status Scale (EDSS) score of 8. The EDSS was developed by John Kurtzke, MD, in 1983 to follow disability over time. This scale of 0 (normal) to 10 (passed away) is not linear, and patients do not move up the scale in a regular fashion. A patient scoring an 8 is not ambulatory and cannot transfer without a lot of assistance. Thus, this person has considerable disability. To date, no pharmacologic treatment is available that restores ability. In a situation such as this, the assumption is that little inflammation is going on in the nervous system; thus, and not surprisingly, the routine MS treatments do not work well.
Almost all patients with progressive MS stop progressing at some point. Obviously, we would like to stop the progression earlier rather than later, but without treatment, progression usually still halts at some point. It is rare to die from MS, but rather, people die with MS.
Treating MS in general is about (1) disease management, (2) symptom management, and (3) person management. If new symptoms and findings occur with progression in between attacks, the use of interferon, glatiramer acetate, or natalizumab is indicated. Mitoxantrone may be indicated for those who continue to progress despite these treatments. Mitoxantrone has risks; thus, the risk/benefit ratio must be evaluated.
At an EDSS score of 8, a rigorous approach toward symptom management is necessary with an emphasis on maintaining function despite the progression. This means regular physical and occupational therapy. Speech therapy may be necessary for swallowing, speech, and cognition. A properly fitting, independently powered wheelchair is essential to maintaining mobility in disability.
The patient needs to be evaluated for psychological, personal, and vocational needs with a plan of care in that arena formulated. Patients have a tendency to withdraw from society. Remaining mobile and active is important to prevent the cognitive dysfunction that results from this isolation.
I truly believe that there are treatments for SPMS, but they require a team approach and rely less on disease management and more on symptom and person management.
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