Multiple sclerosis

Twenty Years of Subcutaneous Interferon-Beta-1a for Multiple Sclerosis: Contemporary Perspectives

Multiple sclerosis (MS) is a chronic, progressive, inflammatory disorder of the central nervous system. Relapsing-remitting MS (RRMS), the most common form of the disease, is characterized by transient neurological dysfunction with concurrent accumulation of disability. Over the past three decades, disease-modifying therapies (DMTs) capable of reducing the frequency of relapses and slowing disability worsening have been studied and approved for use in patients with RRMS. The first DMTs were interferon-betas (IFN-βs), which were approved in the 1990s. Among them was IFN-β-1a for subcutaneous (sc) injection (Rebif®), which was approved for the treatment of MS in Europe and Canada in 1998 and in the USA in 2002. Twenty years of clinical data and experience have supported the efficacy and safety of IFN-β-1a sc in the treatment of RRMS, including pivotal trials, real-world data, and extension studies lasting up to 15 years past initial treatment. Today, IFN-β-1a sc remains an important therapeutic option in clinical use, especially around pregnancy planning and lactation, and may also be considered for aging patients, in which MS activity declines and long-term immunosuppression associated with some alternative therapies is a concern. In addition, IFN-β-1a sc is used as a comparator in many clinical studies and provides a framework for research into the mechanisms by which MS begins and progresses.

A proposed role for nerve growth factor in the etiology of multiple sclerosis

It is proposed that, in addition to genetic factors involved in immune attack on myelin, higher concentrations of nerve growth factor in certain tissues during development determine susceptibility to multiple sclerosis. High early nerve growth factor in some vasculature of spontaneously hypertensive rats increases sympathetic innervation and catecholamine production in these vessels. They become more sensitive than controls to noradrenaline after chemical sympathectomy. Continued exposure to high noradrenaline can result in sympathectomy-like effects, heightening sensitivity to constricting neurotransmitters. Vasoresponses of spontaneously hypertensive rats are impaired with submaximal but not maximal hypoxia. Such a situation in multiple sclerosis patients could result in insufficient blood flow by vasoconstriction until it becomes maximal. Glutamate increase by ischemia and hyperemic release of free radicals could injure neurons, prompting an immune response to myelin proteins in susceptible people. Developmental adaptation to situations requiring lower sympathetic activity might help counteract these effects.

Multiple sclerosis. Observations and reflections--a personal memoir

The pathogenesis of MS has become better understood as a result of recent advances in several areas, particularly in epidemiology and neuro-imaging. A number of epidemiologically based conclusions need to be revised, most importantly the putative direct relationship between prevalence and latitude, and the concept that epidemics of MS have occurred in some parts of the world. It is now clear that genetic factors play a much more important role in the genesis of the disease than environmental factors, although the latter cannot be ignored. The existence of a genetic susceptibility, coupled with either protective or enhancing factors, which may be genetic or environmental, is recognized as being most important in individuals of northern European origin. Much evidence suggests that the disease is initiated by a viral illness (or possibly a vaccination) at some time before puberty. This first antigenic challenge results in the development of what is called the "MS trait", a systemic condition that may never develop into the actual disease and may be observed as well in the unaffected siblings of MS patients. The trait is almost certainly a manifestation of an alteration of the immune system; its most important effect is to render the blood-brain barrier more vulnerable to a variety of agents that will increase its permeability. In order for MS to involve the central nervous system, loss of integrity of the blood-brain barrier is an obligatory step, an observation which has now been amply confirmed by neuroimaging studies. This effect upon the blood-brain barrier appears to be non-specific, since it may result from such diverse causes as a viral infection, a vaccination, or mild trauma. Edema and inflammation follow, but myelinoclasia is not always a consequence; thus plaque formation may not occur and the initial lesion of MS may disappear without leaving a trace. The actual mechanism of myelinoclasia, and the role played in it by lymphocytes, remain unknown. Although the disease does affect the central nervous system, it may remain asymptomatic for a long time after the actual plaque is formed, even for the person's entire life.

HLA antigens in multiple sclerosis amongst Indians

The infrequency of multiple sclerosis in India may have genetic implications. We found (a) the HLA-A3 and HLA-B7 haplotypes amongst Indians to be lower than those reported in Caucasians, (b) no excess of HLA-A3 and HLA-B7 amongst our 27 multiple sclerosis patients compared to 330 controls; instead it was the reverse, (c) HLA-B12 as high as 74% in the "clinically definite" cases, against only 9% in controls, (d) a significant relative risk of MS amongst Indians with HLA-B12 haplotype. Attention is drawn to th higher incidence of MS amongst the small Parsee community and the high association of HLA-B12 in these patients.

Cerebrospinal fluid data. 2. Interpretation in intracranial malignancy and multiple sclerosis

In malignancies involving the CNS, notably leukemia, malignant cells may be readily demonstrated in the CSF, directly confirming the diagnosis. Advances in cell isolation techniques have significantly increased the diagnostic yield of CSF cytology. A variety of CSF protein studies and both WBC and differential counts are central to the diagnosis of multiple sclerosis. Protein studies include total protein levels, gamma globulin levels, and electrophoretic techniques designed to demonstrate the fine structure of gamma globulin, ie, its separation into two to ten (or more) oligoclonal bands. Although by no means specific for multiple sclerosis, such bands are strongly supportive of the diagnosis in the correct clinical setting.

Diagnostic techniques in multiple sclerosis

Although multiple sclerosis (MS) has been an area of great interest and effort in numerous scientific disciplines, its etiology, pathogenesis and therapy remain mysterious. Perhaps the most significant advances have resulted from the ability to be more precise in establishing the diagnosis of MS. Among the most important of the new diagnostic tools are electrophysiological techniques for examination of the visual and oculomotor systems. Tests such as the visually evoked potential (VEP) can confirm the existence of clinically suspected lesions and document the presence of asymptomatic ones. Various electrophysiological techniques for detection and evaluation of MS, as well as CSF analysis, psychological and neuroradiological procedures, and immunological observations are described. The relationship between optic neuritis and MS is reviewed, as are therapeutic regimens in use and under study.