Multiple sclerosis (MS) is a common and blighting neurological disease. It frequently targets young people, often with disabling effects. It may affect any part of the central nervous system, and it manifests with relapsing or steadily progressive clinical features.
Research is improving our understanding of MS at a breathtaking pace. Just as one is getting comfortable with the status quo, a sudden paradigm shift occurs. This is the work of the men and women in white coats, labouring in dingy labs, peering down powerful microscopes, and scrutinising imaging scans-all in the drive to improve the care of people who suffer from this defiant disease. To avoid becoming dinosaurs, neurologists have to keep up with the rapid developments at the cutting-edge of multiple sclerosis.
MS research has enhanced our knowledge of all aspects of the disease. For example, we know a lot more about MS risk factors, as discussed in my previous post titled MS risk factors: the top 6. There is also a lot going on with drug development, as I addressed in my previous blog posts, The emerging progress from the world of MS, and Masitinib, a breakthrough drug shattering neurology boundaries. More importantly, there are many drugs, already in use, which have radically changed neurological practice in a very short time. In this blog post I will review 5 treatments which have already transformed the management of MS.
1. Monoclonal antibodies
It seems a long time ago now when the treatment of Multiple Sclerosis (MS) revolved just around interferons and steroids. Since then the monoclonal antibodies have changed the field radically. Drugs such as natalizumab and alemtuzumab are now mainstream, and many other ‘mabs’ have followed fast on their heels. Daclizumab is about to come into clinical practice soon, and ocrelizumab is full of promise for progressive MS, as discussed in this article in Medscape. With the floodgates now fully opened, other ‘mabs’ such as ofatumumab are trooping in fast. Unfortunately not all monoclonal antibodies are making the grade; an example is Opicinumab (anti LINGO-1), touted as a drug that boosts nerve signals, but which latest reports indicate failed to meet up to its high expectations.
Fingolimod is the leader in the pack of sphingosine-1-phosphate receptor modulators. It has led the way and has the advantage that it is taken by mouth rather than by injection. It is limited by its risks on heart activity, and must be initiated under close cardiac monitoring. Beyond MS, it may have a wider impact on neurological practice as it is under consideration in the treatment of motor neurone disease (MND). Following quickly behind fingolimod, still in trial stages, are laquinimod, ozanimod, ponesimod, siponimod, and amiselimod. It is still not clear if these drugs will have a similar impact as the monoclonal antibodies, in which case we may end up with the war of the ‘Mabs’ versus the ‘Mods’.
3. Dimethyl fumarate
Dimethyl fumarate is an oral MS drug which works by activating the erythroid-derived 2-like transcriptional pathway. It has the stamp of approval of a Cochrane Database review on account of moderate quality evidence from two randomized clinical trials. It is fairly well-tolerated, mild flushing being the commonest reported side effect.
Terifluonomide is another oral drug developed for the treatment of MS. It is a pyrimidine synthesis inhibitor. Unlike dimethyl fumarate, a recent Cochrane database review for terifluonomide found only low-quality evidence from 5 clinical trials. The review says ‘all studies had a high risk of detection bias for relapse assessment, and a high risk of bias due to conflicts of interest‘. Not very glowing tributes, but in its favour is the low frequency of significant side effects.
5. PEGylated interferon
PEG-interferon is an enhancement to good interferons of old (which, by the way, are still on active duty in MS). It was developed to reduce the high frequency of injections associated with Interferon beta-1a. Pegylation is the attachment of polyethylene glycol (PEG), and this process increases the half life of drugs. It is not clear that pegylation offers any other advantage over ‘ordinary’ interferon, but surely the 2 weekly injection is a significant advance.