Multiple sclerosis therapy. A practical guide

Cannabinoids for the treatment of multiple sclerosis: no smoke without fire?

This review evaluates the most recent evidence available on the potential of cannabinoid drugs to relieve spasticity and pain in multiple sclerosis. Many different drugs are used to control the symptoms of multiple sclerosis, periods of relapse and the progression of the disease but it is in the potential management of spasticity, pain and lower urinary tract symptoms that cannabinoids have excited interest. At present, there are relatively few published, controlled clinical studies that support the efficacy of cannabinoids in this context and the evidence that is available is contradictory. On the other hand, the results of unpublished clinical trials are more encouraging and there are other major clinical trials underway. The results of animal studies are also consistent with the hypothesis that endogenous cannabinoids and their receptors are involved in the generation of spasticity and pain.

Corticosteroid resistance in a subpopulation of multiple sclerosis patients as measured by ex vivo dexamethasone inhibition of LPS induced IL-6 production

We assessed corticosteroid sensitivity in multiple sclerosis (MS) patients compared to control subjects, using an in vitro assay of dexamethasone (Dex) inhibition of lipopolysaccharide (LPS) stimulated-blood interleukin-6 production. Significantly higher concentrations of dexamethasone were needed to obtain 50%-inhibition (ID(50)) of in vitro LPS stimulated interleukin (IL)-6 production (28.4 x 10(-7) M) in relapsing-remitting MS (RRMS) patients compared to chronic progressive MS (CPMS) patients (6.2 x 10(-7) M) or compared to controls (3.0 x 10(-7) M). We also found a trend towards worsening of clinical status over time with increasing corticosteroid resistance. These data suggest that corticosteroid sensitivity may be a factor in the pathogenesis and could be used for prognosis of MS.

Reflexology treatment relieves symptoms of multiple sclerosis: a randomized controlled study

OBJECTIVE

To evaluate the effect of reflexology on symptoms of multiple sclerosis (MS) in a randomized, sham-controlled clinical trial.

METHODS

Seventy-one MS patients were randomized to either study or control group, to receive an 11-week treatment. Reflexology treatment included manual pressure on specific points in the feet and massage of the calf area. The control group received nonspecific massage of the calf area. The intensity of paresthesias, urinary symptoms, muscle strength and spasticity was assessed in a masked fashion at the beginning of the study, after 1.5 months of treatment, end of study and at three months of follow-up.

RESULTS

Fifty-three patients completed this study. Significant improvement in the differences in mean scores of paresthesias (P = 0.01), urinary symptoms (P = 0.03) and spasticity (P = 0.03) was detected in the reflexology group. Improvement with borderline significance was observed in the differences in mean scores of muscle strength between the reflexology group and the controls (P = 0.06). The improvement in the intensity of paresthesias remained significant at three months of follow-up (P = 0.04).

CONCLUSIONS

Specific reflexology treatment was of benefit in alleviating motor; sensory and urinary symptoms in MS patients.

A patient with essential thrombocytosis and multiple sclerosis

We report on a patient with a 5-year history of essential thrombocytosis (ET) who developed multiple sclerosis (MS) during the last 5 months. The patient was treated for MS with interferon-beta (IFN-beta), which also had a beneficial effect on the ET. We describe the patient's history and the beneficial effect of IFN-beta administration in reducing the number of platelets. We also discuss the possible link between the pathogenesis of ET and MS.

[Recommendations for the use of immunomodulatory drugs in multiple sclerosis: the BCTRIMS consensus] [Brazilian Committee for Treatment and Research in Multiple Sclerosis]

After brief considerations about clinical course and diagnosis in multiple sclerosis, the members of the BCTRIMS present some recommendations for the use of the immunomodulatory drugs in the treatment of this disease.

Complementary and alternative therapies for treating multiple sclerosis symptoms: a systematic review

Multiple sclerosis (MS) is a chronic disease of the central nervous system without a known cure. Thus the role of complementary and alternative therapies (CATs) for the management of symptoms lies in palliative care and this is borne out by the popularity of these treatments amongst MS sufferers. This review is aimed at determining whether this use is supported by evidence of effectiveness from rigorous clinical trials. Database literature searches were performed and papers were extracted in a pre-defined manner. Twelve randomized controlled trials were located that investigated a CAT for MS: nutritional therapy (4), massage (1), Feldenkrais bodywork (1), reflexology (1), magnetic field therapy (2), neural therapy (1) and psychological counselling (2). The evidence is not compelling for any of these therapies, with many trials suffering from significant methodological flaws. There is evidence to suggest some benefit of nutritional therapy for the physical symptoms of MS. Magnetic field therapy and neural therapy appear to have a short-term beneficial effect on the physical symptoms of MS. Massage/bodywork and psychological counselling seem to improve depression, anxiety and self-esteem. The effectiveness for other CATs is unproven at this time. In all the CATs examined further investigations are needed in the form of rigorous large-scale trials.

Recent developments in drug therapy for multiple sclerosis

Symptomatic treatment of multiple sclerosis (MS) includes a diverse range of drugs intended to relieve the specific symptoms with which a patient may present at a particular point in the progression of the disease. These drugs, not specifically designed for the treatment of MS, may include antispastic agents (e.g. baclofen), drugs to reduce tremor (e.g. clonazepam), anticholinergics (e.g. oxybutynin) which relieve urinary symptoms, anti-epileptics (e.g. carbamazepine) to control neuralgia, stimulants to reduce fatigue (e.g. amantadine), and antidepressants (e.g. fluoxetine) to treat depression. The treatment of acute relapses or exacerbations is dominated by corticosteroids such as methylprednisolone. The most active area of current investigation is the development of drugs which will inhibit the progression of the disease process itself, and in this category the beta- and alpha-interferons are the most effective drugs currently available, although many new treatments are currently in trials, including immunoglobulin, copolymer-1. bovine myelin, T-cell receptor (TCR) peptide vaccines, platelet activating factor (PAF) antagonists, matrix metallo-proteinase inhibitors, campath-1, and insulin-like growth factor (IGF).

Tizanidine. A review of its pharmacology, clinical efficacy and tolerability in the management of spasticity associated with cerebral and spinal disorders

The central alpha 2 adrenoceptor agonist tizanidine is a myotonolytic agent used in the treatment of spasticity in patients with cerebral or spinal injury. Wide interpatient variability in the effective plasma concentrations of tizanidine means that the optimal dosage must be titrated over 2 to 4 weeks for each patient (dosages of 2 to 36 mg/day have been used in clinical trials). Maximum effects occur within 2 hours of administration. Antispastic efficacy has been demonstrated for tizanidine in placebo-controlled trials, with reduction in mean muscle tone scores of 21 to 37% versus 4 to 9% for patients receiving placebo. Improvement in muscle tone occurred in 60 to 82% of tizanidine recipients, compared with 60 to 65% of baclofen and 60 to 83% of diazepam recipients. Spasm frequency and clonus are also reduced by tizanidine. The most common adverse effects associated with tizanidine are dry mouth and somnolence/drowsiness. Muscle strength, as assessed by objective means, appears not to be adversely affected by tizanidine and subjective muscle weakness is reported less often by tizanidine recipients than by those receiving baclofen or diazepam. Global tolerability was assessed as good to excellent in 44 to 100% of patients receiving tizanidine, compared with 38 to 90% of baclofen and 20 to 54% of diazepam recipients. In conclusion, tizanidine is an antispastic agent with similar efficacy to that of baclofen and a more favourable tolerability profile. While drowsiness is a frequently reported adverse effect with both agents, subjective muscle weakness appears to be less of a problem with tizanidine than with baclofen. Tizanidine, therefore, appears to be an attractive therapeutic alternative for patients with spasticity associated with cerebral or spinal damage.