Transfer factor in treatment of multiple sclerosis

Effect of selective serotonin reuptake inhibitors and immunomodulator on cytokines levels: an alternative therapy for patients with major depressive disorder

Major depressive disorder (MDD) is a psychiatric illness that presents as a deficit of serotonergic neurotransmission in the central nervous system. MDD patients also experience alterations in cortisol and cytokines levels. Treatment with selective serotonin reuptake inhibitors (SSRIs) is the first-line antidepressant regimen for MDD. The aim of this study was to determine the effect of a combination of SSRIs and an immunomodulator-human dialyzable leukocyte extract (hDLE)-on cortisol and cytokines levels. Patients received SSRIs or SSRIs plus hDLE. The proinflammatory cytokines IL-1 β , IL-2, and IFN- γ ; anti-inflammatory cytokines IL-13 and IL-10; and 24-h urine cortisol were measured at weeks (W) 0, 5, 20, 36, and 52 of treatment. The reduction in cortisol levels in the SSRI-treated group was 30% until W52, in contrast, the combined treatment induced a 54% decrease at W36. The decline in cortisol in patients who were treated with SSRI plus hDLE correlated with reduction of anti-inflammatory cytokines and increases levels of proinflammatory cytokines at the study conclusion. These results suggest that the immune-stimulating activity of hDLE, in combination with SSRIs, restored the pro- and anti-inflammatory cytokine balance and cortisol levels in depressed patients versus those who were given SSRIs alone.

Plasmapheresis combined with interferon: an effective therapy for multiple sclerosis

The rationale for the use of interferon (IFN) in the treatment of multiple sclerosis (MS) is based on its recognized antiviral and immunomodulating actions. The pathogenesis of MS is believed to be due to an immunologic response in a genetically predisposed individual, localized within the central nervous system white matter, and triggered by exposure to an environmental agent such as a virus. Based on our personal experience we find that the efficacy of IFN therapy is hampered in MS patients by the presence of an interferon inhibitor factor (IIF) in the patients' sera which we have isolated and characterized. When plasmapheresis (PP) was done on 24 MS patients with intermittent 3-day administration of IFN-alpha and human leukocyte IFN, marked increase of IFN in 18 patients and modest increase in three patients correlated with clinical improvement. Three clinical nonresponders showed no increase in IFN levels following therapy. The ability to remove IIF and lymphokine inhibitor factor (LIF) by PP may explain the successful treatment of our patients. We describe the evaluation of helper T cells, suppressor T cells, HLADR antigen, natural killer cells, and monocyte/macrophage cell populations by flow cytometry before and after PP. A significant increase in these immune-competent cells correlated with marked improvement in Kurtzke disability status scale in 13 patients, while eight stabilized. Patients showing progression of the disease either showed decrease or no change in these parameters after therapy. Encouraging results from this pilot study suggest that PP combined with immunomodulatory regimens of IFN may be an effective therapy for MS.

Delta 9-tetrahydrocannabinol: a novel treatment for experimental autoimmune encephalomyelitis

Since multiple sclerosis (MS) is believed to be an immune-mediated disease, it follows that its therapies should be directed towards modulating the immune system. Current MS treatments, which include the use of exogenous steroids that are immunosuppressive, do not meet therapeutic objectives. delta 9-Tetrahydrocannabinol (THC), an active component of marijuana, has been shown to be immunosuppressive. To test THC's ability to suppress an immune-mediated disease, experimental autoimmune encephalomyelitis (EAE), the laboratory model of MS, was used. Lewis rats and strain 13 guinea pigs were administered THC either before inoculation for EAE or treated with THC after injection. Control animals received placebo. The effect of dose, in addition to the timing of treatment, was also investigated. All animals treated with placebo developed severe clinical EAE 10-12 days post-injection (d.p.i.) and more than 98% died by 15 d.p.i. THC-treated animals had either no clinical signs or mild signs with delayed onset (13-15 d.p.i.) with survival greater than 95%. Examination of central nervous system tissue revealed a marked reduction of inflammation in the THC-treated animals. Therefore, as THC has been shown to inhibit both clinical and histologic EAE, it may prove to be a new and relatively innocuous agent for the treatment of immune-mediated diseases.

Variability on serial testing of pattern reversal visual evoked potential latencies from full-field, half-field and foveal stimulation in control subjects

The change in pattern reversal visual evoked potential (PRVEP) latency over time (test-retest variability, TRV) was assessed in 30 (16 males, 14 females) adult control subjects using full-field (FF), half-field (HF) and foveal (central-field, CF) stimulation. The mean test-retest interval (TRI) was 20.5 months with a range of 18-21.5 months. There were no significant test-retest latency differences in either sex and furthermore there were no significant inter-sex differences in any of the test-retest parameters. Because of the latter finding the test-retest upper limit of normal for each parameter as defined by the mean value + 2.5 S.D. was taken as the largest value obtained in either sex. Thus the test-retest upper limits of normal for absolute latency from FF, right HF, left HF and CF stimulation were 6, 7, 9 and 7 msec, respectively; for interocular latency differences (ILD) from FF and CF stimulation were 4 and 5 msec respectively; and for right HF to left HF intraocular latency difference (IOLD) was 7 msec. It is concluded that the TRV was sufficiently small in our control group with each of the stimulus techniques to make all of them potentially useful in serial PRVEP studies. Furthermore the extra information provided by CF and HF stimulation may increase the sensitivity and accuracy with which change can be monitored.

Methisoprinol in the treatment of multiple sclerosis. A pilot study

Twenty-five patients affected by remittent form of multiple sclerosis (MS) were treated with methisoprinol for a period of 2 years. The clinical parameters, recorded during a 2-year observation period preceding onset of therapy, were compared with the analogous measures recorded during treatment. Treatment was associated with significant favourable changes. In fact, there were observed: a reduction in mean annual relapse rate for 22 of 25 patients; an improvement in the clinical status as demonstrated by the reduction of the Kurtzke Disability Status Scale values obtained in 14 of 25 patients; a reduction in the mean period of standard corticosteroid therapy.

Immunological treatment of multiple sclerosis

Immunosuppressive treatment of multiple sclerosis (MS) is based on the autoimmune hypothesis for which the main evidence is the close histological similarity between the human disease and chronic relapsing EAE. Although controlled trials indicate that ACTH is effective in accelerating recovery from relapses, long term ACTH or oral steroids are ineffective. Two controlled trials have suggested a beneficial effect of azathioprine, but neither was conducted "blind" and neither was sufficiently convincing to cause the widespread adoption of azathioprine by neurologists. One controlled trial, also not blind, reported a beneficial effect of an intensive course of cyclophosphamide, but this hazardous treatment will not be widely adopted unless other trials confirm this result. The converse hypothesis that MS is due to a deficient immune response to a virus has led to trials of immunostimulation. Interferon and levamisole have proven ineffective so far, but transfer factor slowed disease progression in one well conducted trial.

Multiple sclerosis: the present position

The advances of the past decade particularly in the application of evoked potential techniques and electrophoresis of CSF proteins have improved the accuracy of early diagnosis of multiple sclerosis. The geographical distribution of the disease, the effect of migration on prevalence, and the existence of clusters suggest that an environmental factor is involved in the aetiology; it is probably infective. Family and twin studies provide evidence for a genetic contribution which is probably multifactorial and related to immune regulation. The pathogenesis is at least in part immunologically mediated. A rational approach to therapy is difficult. In the present state of knowledge we are unlikely to be able to modify the course of multiple sclerosis by tackling a putative environmental agent. We are more likely to be able to do so by manipulating the pathogenesis, although an effective means of doing so has yet to be defined.

Intensive immunosuppression in progressive multiple sclerosis. A randomized, three-arm study of high-dose intravenous cyclophosphamide, plasma exchange, and ACTH

Fifty-eight patients with severe, progressive multiple sclerosis were prospectively randomized to one of three treatments: 20 received intravenous ACTH, 20 received high-dose intravenous cyclophosphamide plus ACTH, and 18 were placed on a regimen consisting of plasma exchange, low-dose oral cyclophosphamide, and ACTH. The three groups were similar in age, sex, duration and type of disease, and degree of disability. Before treatment and six months and one year after treatment, a disability-status score, ambulation index, and functional-status score were determined, and a quantitative neurologic examination was performed. In the ACTH group, the number of patients stabilized or improved was 8 of 20 at six months and 4 of 20 at one year; in the cyclophosphamide-ACTH group, 18 of 20 at six months and 16 of 20 at one year; and in the plasma exchange group, 11 of 18 at six months and 9 of 18 at one year. High-dose cyclophosphamide plus ACTH was most effective in halting progression of the disease at both 6 and 12 months (at 12 months, cyclophosphamide-ACTH vs. ACTH, P = 0.0004; cyclophosphamide-ACTH vs. plasma exchange, P = 0.087). Thus, progressive multiple sclerosis may be stabilized by short-term, intensive immunosuppression with cyclophosphamide plus ACTH.

Modulation of immunity in multiple sclerosis: a double-blind levamisole-placebo controlled study in 85 patients

Levamisole seems to regulate cell-mediated immunity by restoring T-cell function. Since a deficiency of T lymphocytes has been described by various authors in multiple sclerosis patients. Of the 85 patients involved in the trial, evaluation of functional and neurological scores was possible in 54 (32 with placebo and 22 with levamisole). The mean follow-up period was 2 years. This double-blind controlled study indicates that both neurological function and disability significantly deteriorated in the placebo-treated patients, but remained fairly stable in the levamisole-treated group. Since the difference between both groups was not significant, no levamisole effect was demonstrated on progression in multiple sclerosis. With the exception of one case of granulocytopenia (which had no clinical effect), no drug-related changes could be demonstrated. This contrasts with the general impression that this immunomodulator agent might be harmful to patients with multiple sclerosis. The fact that during this blind study both annual relapse rate and disability score remained more stable in treated patients with severe disability suggests that, while waiting for a more effective treatment, long-term levamisole therapy could be useful in patients with multiple sclerosis.

Double-blind controlled trial of immunosuppression in the treatment of multiple sclerosis: final report

In a double-blind controlled trial 43 patients with relapsing-remitting multiple sclerosis were treated either with anti-lymphocyte globulin, prednisolone, and azathioprine, or with placebo preparations. Treatment began with a combination of the three medicaments but after 1 month was continued for another 14 months with azathioprine (3 mg/kg dialy) only. There was a marginally beneficial effect of immunosuppression on the overall relapse rate and clinical progression. However, there were significant effects on in-vitro lymphocyte function and in the visual evoked potentials in favour of the group receiving suppressive treatment. Placebo-treated patients of the HLA A3 tissue type had significantly more relapses than placebo-treated patients who were not of type HLA A3. Nevertheless, HLA-A3-positive patients treated with immunosuppression had significantly fewer relapses than A3-positive placebo-treated patients.

Evoked potential changes in clinically definite multiple sclerosis: a two year follow up study

Visual, spinal and somatosensory evoked potentials were performed on 56 patients with clinically definite multiple sclerosis at the beginning and end of a 2 1/2 year follow-up period. At the initial examination one or both visual evoked potentials were abnormal in all but nine patients (84%), five of whom had abnormalities of either spinal or somatosensory evoked responses; that is, one or more abnormal results were obtained from 52 of 56 (91%) patients. At the final examination there were abnormalities of one or more evoked potentials in 55 of the 56 (98%) patients. There was an increase in latency of the components of the evoked responses over the period; reduction in latency in individual patients was exceptional. The change in these electrophysiological measurements correlated with the increase in clinical disability of the group of patients over the period of study.

Plasma exchange of malignant multiple sclerosis

A 17-year old female with "malignant" multiple sclerosis died 45 weeks after the onset of the disease. Postmortem examination confirmed the clinical diagnosis of multiple sclerosis. After 30 weeks of rapid clinical progression, the patient was treated with two courses of plasma exchange therapy without immunosuppression. This form of therapy caused a drop in cerebrospinal fluid myelin basic protein levels in one instance, but not in another. Controlled clinical trials are required to determine whether plasma exchange therapy is of value in the management of patients with multiple sclerosis, and the monitoring of cerebrospinal fluid myelin basic protein, if elevated, may be one useful marker to follow as part of these studies.