Therapeutic armamentarium in Multiple Sclerosis (MS) has radically changed in the last few decades due to the development of disease modifying treatments (DMTs) with highly selective mechanisms of ...action.
In this review, the authors will focus on the current role of immunosuppressive DMTs in the management of the relapsing-remitting form of MS (RRMS), moving from the rationale of its use and looking at the possibility to design an idealistic scenario of a personalized approach for each single patient.
Questions remain open about whether initial high-efficacy immunosuppressive DMTs improve long-term outcomes, whether prolonged exposure to these agents increases adverse events and what the strongest early surrogate markers are for predicting long-term treatment responses to high-efficacy drugs. In this way, the immunosuppressive DMTs, are used to hit the immune system early and hard with the idealistic goal of striking the autoimmune activities before the neurological damage becomes irreversible.
Multiple sclerosis (MS) is characterized by demyelination and axonal loss that results in progressive disability. Recent advances in understanding the immune pathogenesis of MS resulted in the ...introduction of numerous effective drugs with diverse mechanisms of actions, routes of administration and benefit-risk profiles. New oral drugs recently approved for MS treatment has led to significant achievements in MS management. The oral route of administration promotes patient satisfaction and increases therapeutic compliance; but their introduction has raised concerns regarding safety and tolerability; and a thorough analysis of the benefit/risk ratio is required. This article reviews the mechanisms of action, safety and efficacy of the licensed and experimental oral drugs in MS. Moreover, we put into perspective the disease, drug and patient-related factors that should be taken into account when considering the appropriate oral drug and treatment strategy to the appropriate patient, thus paving the road for personalized medicine in MS.
The prevalence of pain in Multiple Sclerosis (MS) is estimated to be between 29-86% depending on various stages of the disease. According to a recent mechanism-based classification, MS pain syndromes ...include ongoing extremity pain, trigeminal neuralgia, and Lhermitte's phenomenon, painful tonic spasms and spasticity pain, pain associated with optic neuritis, musculoskeletal pain, migraine, and treatment-induced pain.
Pharmacological approaches for MS pain include anticonvulsants, antidepressants, botulinum toxin, cannabinoids, muscle relaxants, opioid analgesics, and intrathecally administered baclofen. It has been reported that pharmacological treatments have poor efficacy and alarming side effects. For these reasons, non-pharmacological interventions, either alone or in combination with pharmacological treatments are commonly used in clinical practice. Examples of these interventions include electrical or chemical neurostimulation therapy, exercise, and psychological approaches. This is discussed in more detail herein.
The management of MS pain can be challenging due to the natural course of the disease and the lack of a definite cure. Recommendations based on rigorous scientific methods for MS pain treatment are unavailable. Thus, clinicians should consider available treatment regimens based on efficacy, safety, cost, and the clinical complexity of the patient. The use of therapeutic approaches combining pharmacological and non-pharmacological treatments may help to reduce the risk of overuse and mitigate the complaint of simultaneous and multiple therapies.
The therapeutic approach in multiple sclerosis (MS) is radically changing. From the early stages of MS, a hard-hitting approach to treatment is taken with strong anti-inflammatory drugs being a ...possible therapeutic option. Areas covered: The concept of induction therapy is emerging in the MS therapeutic scenario. Expert opinion: Not all the MS licensed drugs are suitable candidates for induction therapy. The upcoming challenge will be to identify, after a careful and individual assessment of risk/benefit ratio, the ideal patient who is a candidate to such aggressive therapeutic approach.
Objectives
We compared the clinical, laboratory, and radiological features of different subgroups of acute transverse myelitis (ATM) diagnosed according to the criteria established by the Transverse ...Myelitis Consortium Working Group (TMCWG) as well as of non-inflammatory acute transverse myelopathies (NIATM) to identify possible short- and long-term prognostic factors.
Methods
A multicenter and retrospective study comprising 110 patients with ATM and 15 NIATM admitted to five Italian neurological units between January 2010 and December 2014 was carried out.
Results
A significantly higher frequency of isolated sensory disturbances at onset in ATM than in NIATM patients (chi-square = 14. 7;
P
= 0.005) and a significantly higher frequency of motor symptoms in NIATM than ATM (chi-square = 12.4;
P
= 0.014) was found. ATM patients with high disability at discharge had more motor-sensory symptoms without (OR = 3.87;
P
= 0.04) and with sphincter dysfunction at onset (OR = 7.4;
P
= 0.0009) compared to those with low disability. Higher age (OR = 1.08;
P
= 0.001) and motor-sensory-sphincter involvement at onset (OR = 9.52;
P
= 0.002) were significantly associated with a high disability score at discharge and after a median 1-year follow-up.
Conclusions
The diagnosis of ATM may prevail respect to that of NIATM when a sensory symptomatology at onset occurs. In ATM, patients older and with motor-sensory involvement with or without sphincter impairment at admission could experience a major risk of poor prognosis both at discharge and at longer time requiring a timely and more appropriate treatment.
•CMi refers to the simultaneous performance of a cognitive and a motor task as DT.•CMi is assessed by various techniques able to measure the related brain activity.•FMRI studies showed ...additive/over-additive brain activity as multiple resources are needed.•Specific loci have been identified, although they may depend on the single components.
Cognitive-motor interference refers to dual-tasking (DT) interference (DTi) occurring when the simultaneous performance of a cognitive and a motor task leads to a percentage change in one or both tasks. Several theories exist to explain DTi in humans: the capacity-sharing, the bottleneck and the cross-talk theories. Numerous studies investigating whether a specific brain locus is associated with cognitive-motor DTi have been conducted, but not systematically reviewed. We aimed to review the evidences on brain activity associated with the cognitive-motor DT, in order to better understand the neurological basis of the CMi. Results were reported according to the technique used to assess brain activity. Twenty-three articles met the inclusion criteria. Out of them, nine studies used functional magnetic resonance imaging to show an additive, under-additive, over- additive, or a mixed activation pattern of the brain. Seven studies used near-infrared spectroscopy, and seven neurophysiological instruments. Yet a specific DT locus in the brain cannot be concluded from the overall current literature. Future studies are warranted to overcome the shortcomings identified.
Multiple Sclerosis (MS) manifests with a plethora of signs and symptoms affecting brain structures and spinal pathways. The multitude of lesions in MS patients makes difficult to establish the ...relative role of each of them to lower urinary tract symptoms (LUTS). Generally, the subcortical white-matter lesions result in detrusor overactivity, whilst lesions of the spinal cord result in the combined occurrence of detrusor overactivity and detrusor-sphincter dyssynergia (DSD). It has been estimated that 80-90% of patients with MS will suffer from some form of LUTS over the course of the disease. Among LUTS, the most reported is detrusor overactivity which includes urinary urgency, frequent urination, nocturia, and urge urinary incontinence.
The authors review the management of lower urinary tract symptoms in MS patients providing their expert opinions on the subject matter.
LUTS affect the quality of life substantially and are associated with a significantly increased mortality. The adequate management is an important challenge for both patients and caregivers with a multidisciplinary approach likely necessary.
Pediatric multiple sclerosis (MS) may represent up to 10% of all MS cases. Establishing the diagnosis of MS in a child is complicated by the limited diagnostic criteria and the possibility of ...significant overlap with acute disseminated encephalomyelitis. Areas covered: This review puts in perspective the potential possibilities given by new pharmacological agents in pediatric MS; focusing on the unmet needs in terms of research development in this field. Expert opinion: The treatment landscape of MS has dramatically changed in the last 5 years. However, children are receiving licensed therapies for adult MS (generally first line therapies) in an arbitrary manner and our understanding of such treatments effects and tolerability in children is limited. Of critical importance, we need clinical trials of newer MS agents in children. Further research is needed to have a positive impact for children with MS.
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