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Pharmacologic Treatment of Nystagmus in Multiple Sclerosis

At least half of all people with multiple sclerosis (MS) are expected to have nystagmus at some point during the course of their illness. Nystagmus results from demyelination that involves the brainstem or cerebellar eye movement pathways. While it may be asymptomatic, it often causes blurred vision or oscillopsia. The extent of the visual disturbance is directly related to the velocity of the slow phase of the nystagmus.

In MS patients with chronic nystagmus, the most common form is an acquired pendular nystagmus (APN), which is almost always accompanied by optic atrophy, and often by internuclear ophthalmoplegia (INO).

Numerous treatment trials have demonstrated the efficacy of pharmacologic treatment of chronic symptomatic nystagmus. Treatment should be considered in individuals in whom blurred vision or oscillopsia is severe enough to warrant the potential risk of medication side effects. As a general rule, drugs used to treat nystagmus are titrated slowly upwards from a low dose to either efficacy or tolerance.

The two most effective medications for APN in MS are....

Emerging therapies in multiple sclerosis

Multiple sclerosis is unique among neurological diseases in that there are currently eight treatments for this one condition that have received approval by the U.S. Food and Drug Administration (FDA). Five of these drugs require subcutaneous or intramuscular injection, two are administered intravenously, and fingolimod, the newest agent on the block, is given orally. None are considered curative, but these disease-modifying therapies (DMT) have led to a reduction in relapse rates and the progression of disability.

Despite this progress, each of the drugs comes with side effects, including flu-like symptoms with the interferons, lipoatrophy with glatiramer, progressive multifocal leukodystrophy (PML) with natalizumab, and congestive heart failure or leukemia with mitoxantrone. As the first oral agent for MS, fingolimod created great expectations prior to FDA approval. Its popularity, however, has been surprisingly limited, presumably due to the potential for unknown long-term risks. The occur rence of PML with natalizumab demonstrated to MS neurologists and patients the potential risks associated with new drugs.

Additional DMTs in the pipeline may increase MS-management effectiveness in coming years, although safety will continue to be a major consideration in the use of these drugs. For instance, oral cladribine was on the verge of FDA approval in early March when the agency referred the drug back for more safety studies. This drug is already used in intravenous form for the management of hairy cell leukemia, but it is being studied for use with remitting relapsing MS because of its apoptotic effects on lymphocytes. If cladribine is ultimately approved for use, the risk of infection and neoplasms may limit its use.

Other oral agents being studied include:

Expecting the Best in Pregnancy and Multiple Sclerosis

Considering that multiple sclerosis (MS) affects primarily women of childbearing age, it comes as no surprise that for many patients MS and pregnancy often occur together. The issues to consider when discussing pregnancy and MS include:

  • How pregnancy affects MS
  • How MS affects pregnancy
  • How MS treatment should be managed throughout pregnancy

The Pregnancy in MS (PRIMS) study of 254 patients revealed that pregnancy is generally protective against MS relapses, in particular during the third trimester. In contrast, the same study found a rebound of relapses during three months post delivery, with 30 percent of women experiencing a relapse within three months after delivery. Several strategies have been proposed to avert the risk of postpartum relapse, including the use of prophylactic IVIG or corticosteroids. More recently, exclusive breast-feeding has been found to offer some protection against postpartum MS activity; however, this finding was disputed in a subsequent study.

There is no evidence ...

Questionable Hope for CCSVI in Multiple Sclerosis

Once again, multiple sclerosis patients’ area buzz over a new theory and treatment for the disease. The theory is called chronic cerebrospinal venous insufficiency (CCSVI); and, this time, social media is driving the patient excitement.

CCSVI is based on a controversial idea that impaired venous drainage of the brain due to blockage in venous structures causes MS. Increase in venous pressure promotes leakage of blood across capillaries, with inflammation resulting from the iron deposition into the brain. In 2009 Paolo Zamboni, M.D., reported that virtually all MS patients in a study had abnormalities in the jugular or azygous veins, whereas no control patients had such findings. The Zamboni, or Liberation, procedure involves either angioplasty or stenting of the abnormal vein. Many MS patients are understandably enthusiastic about this theory and treatment.

There are, however, a number of problems with the CCSVI theory that patients and MS neurologists should consider.

 

Multiple Sclerosis Center 2nd Annual Art Show 2011

The Multiple Sclerosis Center at Swedish Neuroscience Institute is hosting its Second Annual Multiple Sclerosis Center Art Show at the Bellevue Arts Museum on Saturday and Sunday, June 18 & 19, 2011 from 11:00am to 5:00pm. There will be an ‘Artist Only Meet ‘n’ Greet, Sunday June 19th from 3pm – 5pm

Entry Criteria:

Exciting Advances in Multiple Sclerosis from ECTRIMS

There is exciting news from last week’s 26th Congress of the European Committee for the Treatment and Research in Multiple Sclerosis (ECTRIMS) in Gothenburg, Sweden.

ALEMTUZUMAB. 5-year data from a Phase II extension study for alemtuzumab, an intravenously administered monoclonal antibody, showed that the drug:

  • reduced annualized rate of relapse to 0.14 compared with 0.28 for interferon
  • reduced the risk for sustained accumulation of disability in remitting relapsing multiple sclerosis by 87% compared to 62% with interferon.

This is a remarkable agent with excellent activity in MS. Adverse events included immune thrombocytopenic purpura, thyroiditis and anti-glomerular basement membrane disease.

TERIFLUNOMIDE. A Phase III trial of oral teriflunomide in remitting relapsing MS showed:

  • a 31% reduction in relapse rate and increased time to first relapse compared with placebo
  • reduced the risk of sustained disability progression by 29.8%.

Side effects were mild and included diarrhea, nausea, liver function abnormalities and hair loss.

Alemtuzumab and teriflunomide are currently in Phase III clinical trials at SNI.

SNI PRESENTATIONS:

  • Dr. Jim Bowen presented a poster about ongoing demyelination and neurodegeneration in a patient who had undergone autologous stem cell transplantation.
  • Drs. Jung Henson and Mayadev reviewed the beneficial effects of exercise on functional and quality of life outcomes from SNI’s MS wellness program

Swedish Smyelin Babes Kick Into High Gear

 
The Bike MS Ride in Mount Vernon is almost here (September 11-12) and the Swedish Smyelin Babes bike team is 98 members strong and still growing! The team started out with 4 riders in 2006, and since then has grown to be the largest bike team, beating out even corporate groups like Team BP, Microsoft, Columbia Athletic Club and Point B. We are also the only bike team representing any of the MS centers in the Seattle region. Last year we raised over $84,000 to support the National Multiple Sclerosis Society, and we hope to beat that amount this year. Join Swedish Smyelin Babes or donate to this worthy cause!
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