MULTIPLE SCLEROSIS

Dr Sadik AL Ghazawi

Associated Professor

Neurologist

MRCP,FRCP UK

What is Multiple Sclerosis (MS)?

1-CHRONIC Autoimmune demyelination

disease of

CNS:

a- brain

b-optic nerve

c- and spinal cord

2-Affects 2.3 million people in the world

What is the epidemiology of MS?

• Geographic distribution

What are the possible risk factors?

1-Infections : viral ,bacterial, fungal.

2-Age: 15yr.-45yr.

3-Gender :female: male 3:1

4-Genetic Factors

5-DR15 haplotype

6-Autoimmune diseases

7-Race

8-Climate

What are the possible triggers of MS?

1-Epstein-Barr Virus

2-Smoking

3-Vitamin-D deficiency

What is the genetic factor?

• The risk of getting MS is approximately:

– 1/750 for the general population (0.1%)

– 1/40 for person with a close relative with MS (3%)

– 1/4 for an identical twin (25%)

• 20% of people with MS have a blood relative with MS

The risk is higher in any family in which there are

several family members with the disease (aka

multiplex families)

Genetics

1-the probability of developing the disease is higher in relatives of an affected

person, with a greater risk among those more closely related.

EXAMPLE identical twins both are affected about 30% of the time, while around 5% for non-

identical twins and

3-if both parents are affected the risk in their children is 10 times that of the

general population. 4- MS is also more common in some ethnic groups than others

What RISKS OF MS?

1-Genetic

Predisposition

2-

Environmental

Trigger

Autoimmunity

Loss of myelin

& nerve fiber

What happens in MS?

...cross the blood-brain barrier…

…launch attack on myelin & nerve fibers...

“Activated” T cells...

…to obstruct nerve signals.

myelinated nerve fibermyelinated nerve fiber

How are myelin autoreactive T-cells

activated?

1-Myelin-reactive T-cells

Myelin basic protein (MBP)

2-T-cell activation

Autoantigens

Molecular mimicry

3-Immune cell recruitment

CD8+ cells

B cells

Granulocytes

Monocytes

Mast cells

What happens once across the BBB?

1-Reactivation of CD4+ cells

Proinflammatory cytokines

2-Microglial and astrocyte activation

Myelin phagocytosis

3-Humoral response

4-B cell co-stimulation of CTLs

5-Demyelination

Type II hypersensitivity

CTL apoptosis

Reactive species

https://michellepetersen76.files.wordpress.com/2

015/05/discovery-of-a-treatment-to-block-the-

progression-of-multiple-sclerosis-

neuroinnovations.jpg

What causes neuronal degeneration?

MS lesions

1-Active lesions

2-Inactive, chronic lesions

Demyelination

Immune mechanisms cause:

1-Oligodendrocyte damage------

2-Injury and loss of axon

3-Gliosis

Lublin et al, 2014

The relapsing-remitting subtype.

1---80-85 present.

2---female predominant.

3-- characterized by unpredictable rapid onset relapses

followed by period of months or years of partial or

complete recovery.

➢4--Attack is a symptoms or objectively observed signs suggestive demyelinationprocess with duration of at least 24 hours, in the absence of fever or infection.

➢5-For paroxysmal symptoms (such as paroxysmal dysarthria, tonic spasms, or paroxysmal sensory symptoms) to be considered an attack, must be recurrent over at least 24 hours.

6--Once MS has been established ,we must evaluate for evidence of

dissemination in space( DIS) (multiple areas) , and for dissemination in

time( DIT)(ongoing disease activity over time).

7-- Deficits that occur during attacks may either

A-Resolve or leave problems in about 40% of attacks.

B-being more common the longer a person has had the disease.

8-When deficits always resolve between attacks, this is

sometimes referred to as benign

MS, although people will still build up some degree of disability in

the long term.

Secondary Progressive MS

• 1-Majority of RRMS many years following onset

• 2-Progressive impairment (spastic gait disturbance) between or

in absence of attacks

– with ongoing relapses

– Substantial ongoing on new MRI inflammatory lesions

➢1-25% to 40% of patients with relapsing remitting MS go on to a secondary progressive course after an average of about 20 years.

➢2-diagnosed when, after an initial relapsing-remitting course, a patient demonstrates disease progression independent of relapses for at least 6 months.

➢3-deterioration with respect to gait, balance,spasticity, and bladder

function ,Many patients experience cognitive decline.

Primary Progressive MS

• Presents with progressive myelopathic gait, cerebellar ataxia or cognitive impairment without clear history of any clinical attacks

• Clinical progression must be for at least 1year and accompanied by a combination of brain&spinal abnormalities and/or CSF abnormalities consistent with MS

The primary progressive subtype=-

1- occurs in approximately 10–20% of individuals,

with no remission after the initial symptoms.

2- It is characterized by progression of disability

from onset, with no, or only occasional and minor,

remissions and improvements.

3-10% to 15%.

4-insidious onset of symptoms followed by gradual deterioration over time.

5-Clinical disease in these patients typically presents as a progressive myelopathy, and less frequently as a brainstem or cerebellar syndrome.

6-Older.

7-no clear gender predominance

8-MRI lesions :➢ fewer in number

➢less likely to enhance with gadolinium compared to relapsing-remitting MS.

9-The usual age of onset for the primary progressive

subtype is later than of the

relapsing-remitting subtype.

10-- It is similar to the age that secondary progressive

usually begins in relapsing-remitting MS, around 40 years

Clinically Isolated Syndrome (CIS)

1-A first neurologic event suggestive

of demyelination

2-Individuals with CIS are at high risk

for developing clinically definite MS if

the neurologic event is accompanied

by multiple, clinically silent

(asymptomatic) lesions on MRI typical

of MS

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CLINICALLY ISOLATED SYNDROM (CIS)

1-the condition begins in 85% of cases as clinically isolated syndrome (CIS) .

2--45% having motor or sensory problems.

3--20% having optic neuritis, and

29

4-10% having symptoms related brain stem dysfunction,

5-while the remaining 25% have more than one of the previous

difficulties

Radiologically Isolated Syndrome (RIS)

– No typical symptoms of CNS demyelination

– No formally accepted diagnostic criteria

– MRI : Typical MS lesions

– CSF abnormalities

– Clinical MS Attack:

– 35% over 5 years

– MRI progression:

• 59-83% in 2 years

Okuda DT et al, Neurology2011:76()8, 686-692

What are the symptoms of MS?

Early symptoms

Daily effects

Age range

Characteristics of symptoms

Cycle of MS Symptoms:

Related and Interdependent

Sleep

Fatigue

Depression

Bladder

& Bowel

problems

Sexuality

issues

Spasticity

Constipation

Cognitive

function

Features Consistent With MS

• Relapses and remissions

• Age Onset between ages 15 and 50

• Optic neuritis

• Lhermitte's sign

• Internuclear ophthalmoplegia

• Fatigue

• Uhthoff's phenomenon

How is MS diagnosed?

MS is a clinical diagnosis

1-Medical history

2-SIGNS And symptoms

3-Laboratory tests

Requires dissemination in time and space:

1-Space: Evidence of scarring (plaques) in at

least two separate areas of the CNS (space)

2-Time: Evidence that the plaques occurred

at different points in time

There must be no other explanation

Diagnosis of MS

1-No single test for diagnosing MS

2-Usually diagnosed when all other possibilities ruled

out

3-Many tests

A-Medical history

B-Nervous system functioning

C-MRI McDonald criteria

D-Evoked potential tests, spinal tap

INITIAL SYMPTOMS

1- ascending numbness starting in the feet;- bilateral hand

numbness;- hemiparesthesia;- dysesthesia in one of the above

distributions;- generalized heat intolerance

Sensory systems:

2--Lhermitte's sign-dysesthetic pain-paresthesia-numbness-dorsal column

signs (i.e.,. severe decrease or loss of vibratory sense and

proprioception,

Ongoing Symptoms and Signs

Motor system:-

3-weakness (variable severity mono- and paraparesis, hemiparesis,

quadriparesis)-

4-increased spasticity resulting in spastic gait

5-pathologic signs (Babinski's, , Hoffmann,etc.) -dysarthria

Cerebellar signs

1-incoordination (dysdiadochokinesia, problems with heel-to-shin test)-slowing

of rapid repeating movements-cerebellar ataxia (ataxic gait)

2-scanning speech-

3-loss of balance

Expanded Disability Status Scale

What tests may be used to help

confirm the diagnosis?

1-Magnetic resonance

imaging (MRI)

2-Visual evoked potentials

(VEP)

3-Lumbar puncture

McDonald Diagnostic CriteriaMRI-High Specificity & Sensitivity for MS

Typical MS demyelinating lesions meeting at least 3 of the

following 4 criteria:

1-At least 1 Gd lesion or at least 9 T2 lesions

2-At least one infratentorial lesion

3-At least one juxtacortical lesion

4-At least 3 periventricular lesions

McDonald Diagnostic Criteria

MRI-Dissemination in Time

If the first MRI is performed 3 months after the clinical event, 1 of the 2 below must be found:

> 1 Gd lesion not at site of original attack; or

MRI 3 months later showing a new T2 or Gdlesion

44

If the first MRI is performed < 3 months after the clinical event,

then a second MRI done 3 months after the attack provides evidence for DIT

if 1 of the 2 below must be found:

New Gd lesion on the second MRI

Later MRI showing new T2 or Gd lesion

Case : MRI Brain

Case 2: MRI Spine

Case 1: Fundoscopy

© Copyright Annals of Internal Medicine, 2014

Ann Int Med. 160 (4): ITC4-1.

What role does lumbar puncture play in

diagnosis?

➢ Spinal fluid can reveal signs of MS

❑ Unique oligoclonal bands in spinal fluid by isoelectric

focusing (in 90%-95% of patients with MS)

❑ Elevation of IgG index (in 50%-75%)

❑ Mild pleocytosis (in ≈50%)

➢ Negative CSF result alone doesn’t rule out MS

❑ But when clinical and radiologic suspicion is low, a normal

CSF result reassures patients they probably don’t have MS

➢ For RRMS diagnosis

❑ Criteria don’t require confirmation by CSF testing

➢ For PPMS diagnosis

❑ Test CSF if MRI features don’t meet criteria for dissemination

in space

Case : CSF Oligoclonal bands

© Copyright Annals of Internal Medicine, 2014

Ann Int Med. 160 (4): ITC4-1.

What are the differential diagnoses?

➢ Other demyelinating diseases

❑ Acute disseminated encephalomyelitis

❑ Neuromyelitis optica (Devic disease)

❑ Idiopathic transverse myelitis

➢ Systemic inflammatory disease

❑ Systemic lupus erythematosus

❑ The Sjögren syndrome

❑ Sarcoidosis

❑ The Behçet syndrome

➢ Metabolic disorders

❑ Adult-onset leukodystrophy

❑ Vitamin B12 deficiency

❑ Copper deficiency

❑ Zinc toxicity

❑ Vitamin E deficiency

© Copyright Annals of Internal Medicine, 2014

Ann Int Med. 160 (4): ITC4-1.

➢ Infections

❑ HIV, Lyme disease, syphilis

❑ Human T-lymphotropic virus

➢ Vascular disorders

❑ Sporadic and genetic stroke syndromes

❑ CNS vasculitis

❑ The Susac syndrome

❑ Dural arteriovenous fistula

➢ Migraine

➢ Neoplasia (i.e., primary CNS neoplasm (glioma or lymphoma)

or metastatic disease)

➢ Paraneoplastic syndromes

➢ Somatoform disorders

An Overview of Treatment Strategies

How is MS treated?

1-There is no cure for MS

2-Treatments FOR:

A-MS attacks or acute relapse.

B-Immune Modify agents

to prevent progression and reduce activity

Of the disease.

3-Treatment of symptoms

HOW SHOULD CLINICIANS CHOOSE THERAPY FOR PATIENTS WHO ARE HAVING AN ACUTE RELAPSE?

• Relapse: new or worsening neurologic symptoms

lasting ≥24h without clear underlying triggers of

pseudo-relapse

➢ Standard treatment: high-dose corticosteroids

❑ IV infusion methylprednisolone, 1g/d for 3-5 days .

➢ OTHER treatment if relapse doesn’t respond to steroids

❑ Plasma exchange

❑ 5 days of IM or SC adrenocorticotrophic hormone .

❑ Pulse-dose IV cyclophosphamide

Disease-Modifying Drugs for RRMS

1-All reduce attack frequency and severity, reduce lesions on MRI, and probably slow disease progression.

2-These medications are not designed to:

A-Cure the disease

B-Make people feel better

C-Alleviate symptoms

How is the disease course treated?

Thirteen disease-modifying therapies are FDA-approved for relapsing

forms of MS:

glatiramer acetate (Copaxone®; Glatopa™ - generic equivalent)

[inj.]

interferon beta-1a (Avonex®, Plegridy™, Rebif®) [inj.]

interferon beta-1b (Betaseron® and Extavia®) [inj.]

dimethyl fumarate (Tecfidera™) [oral]

fingolimod (Gilenya™) [oral]-MELLIOR ORAL

teriflunomide (Aubagio®) [oral]

alemtuzumab (Lemtrada™) [Inj.]

natalizumab (Tysabri®) [inf]

mitoxantrone (Novantrone®) [inj.]

Treatment AMildly effective, mildly toxic

Disease active

Escalation Strategy

Disease suppressed Disease still active

Treatment BMore effective, more toxic

Disease suppressed Disease still active

Treatment CMost effective, most toxic

Incr

eas

ing

eff

icac

y

Increasing burden of treatment(worse safety, more difficult administration)

Interferon-beta

NatalizumabJC+

Mitoxantrone

FingolimodDimethyl fumarate

Autologous stem cell transplantation

Glatiramer

First, second and third line therapies

Laquinimod

Alemtuzumab

NatalizumabJC neg

Rituximab / ocrelizumab

Teriflunomide

Third line

Second line

First line

Daclizumab

Incr

eas

ing

eff

icac

y

Increasing burden of treatment(worse safety, more difficult administration)

Interferon-beta

NatalizumabJC+

Mitoxantrone

FingolimodDimethyl fumarate

Autologous stem cell transplantation

Glatiramer

High and low risk treatments

Daclizumab

Laquinimod

Alemtuzumab

NatalizumabJC neg

Rituxmab / ocrelizumab

Teriflunomide

“Dangerous”

“Aggressive”

“Safe”

IFNβ-1b SC qod

GA

SC qd

IFNβ-1a IM qwk

Mitox

IV q 90

d wks

IFNβ-1a SC tiw

Natalizuma

b

IV q 4 wks Fingolimo

d

0.5 mg gd

Teriflun

PO qd

Laquin

PO

Daclizuma

b

SC

BG-12

PO bid

Alemtu

z

IV

The Changing Landscape of MS Disease Modifying Treatment

Of Approved and Emerging Therapies

Slide 64 of 26

FDA-approved disease modifying agents

• Interferon beta

– Interferon beta-1b (Betaseron®) 250 mcg qod

– Interferon beta-1a (Rebif®) 44 mcg SC TIW

– Interferon beta-1a (Avonex®) 30 mcg IM weekly.

– Commn side effects: inj.site reactions,flu like symptoms,abdominal pain,depression,abn.liver function

• Glatiramer acetate (Copaxone®)

– 20 mg\ml SC \day or 40mg\ml 3 times\week.

– Side effects: vasodilatation,rash,sob,chest pain,anexiety.

• Mitoxantrone (Novantrone®)

– 12 mg/m2 q3mo: lifetime max, 144 mg/m2

– Side effects: nausea,hair thinning,bladder infection.low wbc,and

platletes

• Natalizumab (Tysabri®)

– 300 mg IV monthly infusion

Side effects: UTI,RTI,DIAREA,PML,ENCEPHALITIS

Slide 65 of 26

• Continue disease modifying drugus

• Parenteral (IV) drugs

– Monoclonal antibodies: rituximab/ocrelizumab, alemtuzumab,

daclizumab

• Oral Drugs

– Fingolimod, teriflunomide,Dymethyl fumarate, laquinimod

• Symptomatic therapies

– Fampridine (4-AP), nerispirdine

Glatiramare acetate(copaxon)

Glatiramer acetate, the active ingredient of COPAXONE, consists of the acetate salts of synthetic polypeptides

containing four naturally occurring amino acids: L-glutamic acid, L-alanine, L-tyrosine, and L-lysine

COPAXON

• COPAXONE 20 mg per mL: administer once per day

or

• COPAXONE 40 mg per mL: administer three times per week

FINGOLIMOD

Sphingosine-1-Phosphate (S1P) Receptor Agonist

Fingolimod

Treatment with fingolimod 0.5 mg:

Significant benefits on relapse-related outcomes within first 3 months

and on volume loss over 6 months effects of fingolimod treatment

Injectable therapiesOral therapies

Consider side

effects

BG 12

Fingolimod0,5mg\

day

DIMETHYL

FUMARATE

Terflunomide

Natalizumab 300MG

I.V inj.\month

Glatiram

er

Interferon

β

Relapsing inflammatory MS clinical course

First lineFirst

line?

Severe relapsing

inflammatory

MS/JCV negative

Inadequate

response/inj

intolerance

Inadequate

response/oral

intolerance

Parallel switch

Inadequate

response/JCV

negative

What is the prognosis?

One hallmark of MS is its unpredictability.

Approximately 1/3 will have a very mild course

Approximately 1/3 will have a moderate course

Approximately 1/3 will become more disabled

• Certain characteristics predict a better outcome:

Female

Onset before age 35

Sensory symptoms

Monofocal rather than multifocal episodes

Complete recovery following a relapse

Who is on the MS “Treatment Team”?

• Neurologist

Urologist

Nurse

Physiatrist

Physical therapist

Occupational therapist

Speech/language pathologist

Psychiatrist

Psychotherapist

Neuropsychologist

Social worker/Care manager

Pharmacist

Primary care physician

So what do we know about MS?

MS is a chronic, unpredictable disease

The cause is still unknown

MS affects each person differently; symptoms vary

widely

MS is not fatal, contagious, directly inherited, or always

disabling

74

Early diagnosis and treatment are important Significant,

on

Available treatments reduce the number of relapses and may slow

progression

Treatment includes: attack management, symptom management,

disease modification, rehab,

emotional support

THANK YOU