Currently available therapies for MS have limited efficacy, are not well tolerated, and have a very high cost.40-42
Treatment goals for relapsing MS are, in the short term, to achieve a remission of symptoms, and, in the long term, to minimize structural damage. It is recommended that treatment begins immediately, since patients who receive early treatment have slower progression. The true onset of MS may be long before the first clinical symptoms become evident, and axonal damage can already be detected at early stages of the disease. Thus, early treatment may impact progression by minimizing damage accrual. It is generally recommended that immunomodulatory treatments be continued indefinitely, unless a better therapy becomes available, there is no detectable benefit, or side effects are intolerable.
With natalizumab currently available only in clinical trials, IFN-b or glatiramer acetate are the first line of therapy (both discussed above). There are currently multiple clinical trials comparing IFN-b and glatiramer acetate in isolation and combination. The results from these studies will help refine currently available treatment strategies. Short-term pulse administration corticosteroids can be used alone or in combination with these therapies to hasten recovery from acute relapse.
IVIg or PE is indicated as a second-line therapy for treating severe disabling relapses, when first-line therapies are not effective, tolerated, or appropriate (e.g., women contemplating becoming pregnant). Mitoxantrone is a second-line therapy for patients with worsening MS despite first-line treatment, or for those with inflammatory episodes not responsive to corticosteroids, IVIg, or PE.
Symptomatic therapies are the cornerstone of therapy for patients with SPMS - to reduce neurological impairment and decrease disability and handicap.43 For relapsing progressive forms of MS, IFN-b or mitoxantrone are indicated. For both relapsing and progressive forms of MS, cyclophosphamide has questionable efficacy combined with serious adverse effects and, as such, is only considered an option for patients who do not respond to other treatments (see Figure 1 and Table 2). Another antineoplastic agent, methotrexate (see Figure 1 and Table 2), appears to have modest efficacy for patients with relapsing forms of MS.
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