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Ana sayfa | MSin Derinliği | MS Slide Resource |
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The management of MS can be broadly divided into four main areas:
The remainder of this text outlines how the first three of these management areas are used together in the treatment of the MS patient. An account of the management of MS patients cannot be easily categorized using the different types of disease progression outlined previously. A more appropriate approach is to consider the management of different stages of the disease. The timing of these stages obviously varies with the different types of disease progression. Early disease courseIn the early stages, most MS patients experience little disability. A major management issue at this stage is helping patients come to terms with their diagnosis. Uncertainty about the future can be a psychological burden for sufferers and their families. This is best dealt with by emphasizing hopeful possibilities. Most patients respond well to an explanation of the disease, and assurance that vigorous research is underway to develop better treatment.12,23 Patients should be encouraged to live as normal a life as possible, and seek medical attention when their disease is active. Brief courses of corticosteroids may shorten exacerbations (see 'The role of corticosteroids').14,15,24 It is difficult to offer a prognosis at this stage. Even progressive disease may show long periods of clinical stabilitesini. A widely-quoted study by Kurtzke et al. shows that disability status 5 years after disease onset is highly predictive of disability status 10 and 15 years after onset.25 However, this type of study has no individual value and the introduction of new treatments may modify these findings. Others factors have been identified that may help to predict future course; factors suggesting a poor prognosis are:
After 10 years, 85% of patients are still alive, and about 50% can still carry out their household and/or employment responsibilities. Survival at 25 years is 75 - 85%.9,12,27,28
Late disease courseDespite much initial variation, patients with more severe forms of MS develop a characteristic clinical state with time. A typical patient with late disease has abnormal vision, slurred speech, tremor, spastic-ataxic gait, bladder symptoms, sexual problems and cognitive impairment.9 As the disease progresses further, walking becomes more difficult and patients are forced to adopt a wheelchair existence. Complete urinary incontinence is frequent. Tremor renders the arms useless, and the patient adopts a flexed posture which eventually becomes permanent and is reinforced by contractures. This posture can eventually make even wheelchair life impossible and the patient becomes bedridden9,10 Management of disability is the major requirement in these later stages. Rehabilitation medicine plays a dominant role, including physiotherapy and occupational therapy. In the very late stages, survival depends on nursing care.9,13
The role of corticosteroidsCorticosteroids are the standard treatment for acute exacerbations of MS. They reduce inflammation and modify the cytokine network. In doing so, they reduce the duration of an exacerbation, but they have not been shown to alter the course of the disease. Although the original benefits of steroid therapy in MS were demonstrated using adreno-corticotrophic hormone (ACTH), synthetic corticosteroids are now widely used. This is because they are more potent, and cause less sodium retention and less potassium loss, than ACTH. In addition, they have a more rapid onset and longer duration of action than ACTH.29 Rationale for use and mechanism of action in MS The rationale for using corticosteroids in MS is based on their anti-inflammatory and immunosuppressive actions. Corticosteroids reduce oedema and other aspects of inflammation mainly by inhibiting a phospho-lipase enzyme involved in inflammatory processes.30 The immunosuppressive actions of corticosteroids include prevention of T- and B-lymphocyte proliferation and inhibition of the release of interferon gamma.31 MRI studies indicate that corticosteroids reduce the loss of integrity of the blood-brain barrier during an exacerbation.14 This restoration of the blood-brain barrier has an anti-oedema benefit, and may prevent circulating toxins, viruses or immunoactive cells from entering the CNS.32 Corticosteroids have also been shown to cause a temporary improvement in nerve conduction through demyelinated areas.30 |
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Clinical studies Studies in acute exacerbations Numerous studies, and over 40 years of clinical experience, clearly indicate that corticosteroids hasten clinical recovery from an acute exacerbation of MS. The results of these studies, however, also indicate that short courses of treatment (days to weeks) do not prevent further exacerbations or disease progression.31 Milligan et al. studied the effects of high dose methylprednisolone in 50 MS patients. Of these, 22 patients were in acute relapse. Patients were randomized to receive either 500 mg intravenous (i.v.) methylprednisolone or placebo daily for 5 days. The results from the 22 patients in acute relapse showed that treatment with methyl-prednisolone resulted in a significant decrease in clinical disability scores at 1 and 4 weeks after treatment compared with controls (p<0.05). At 4 weeks, 77% of methylprednisolone-treated patients showed a decrease in Disability Status Scale (DSS) score of at least one point compared with only 22% of control patients (see figure 4.4). Furthermore, all methylprednisolone-treated patients were well enough to be discharged from hospital after 1 week, whereas placebo-treated patients required longer admissions, more physiotherapy and more nursing care.33 Studies in progressive forms of MS A limited number of clinical studies indicate that short courses of corticosteroids produce symptomatic improvement in some patients with the progressive form of MS. The extent and duration of improvement, and the optimum dosing regimen in such cases have not been established.31 Chronic treatment with corticosteroids Studies conducted show that chronic use of these drugs does not alter the frequency of exacerbations or prevent disease progression. Furthermore, prolonged corticosteroid administration is associated with a high risk of adverse effects. The value of intermittent short courses of corticosteroids has not been determined, and an evaluation of the risks and benefits of this approach is needed.31,32 The Optic Neuritis Treatment Trial Beck et al. recently studied the effects of corticosteroids on optic neuritis - often the first sign of MS. They showed that patients treated with a short course of high-dose i.v. methylprednisolone followed by an oral prednisolone taper recovered vision faster than patients treated with placebo. The regimen used was i.v. methyl-prednisolone (250 mg every 6 hours) for 3 days, followed by oral prednisolone (1 mg/kg daily for 11 days, then reducing to zero over 3 days). In contrast, the rate of visual recovery in the patients treated with oral prednisolone alone did not differ from that of the patients treated with placebo. Moreover, new attacks of optic neuritis occurred more frequently in the 2 years following treatment in the oral prednisolone group than in either the placebo or the methylprednisolone group.34 Further analysis of the data from this study suggested that the high-dose i.v. methylprednisolone regimen reduced the risk of development of definite MS over the subsequent 2 years. This benefit was not apparent in patients treated with oral prednisolone alone.35 These results are proving to be controversial, and further investigation is needed before definite conclusions can be made. Corticosteroids in clinical use Choice of drug The synthetic corticosteroids methylprednisolone, prednisolone, prednisone, and dexamethasone are most often used to treat MS exacerbations. They have stronger glucocorticoid and weaker mineralocorticoid properties than cortisone.31 Route of administration A recent study showed that equivalent doses of i.v. and high dose oral methylprednisolone would be equally effective and safe.36 Nevertheless, most neurologists are reluctant to treat acute exacerbations with oral corticosteroids alone because of the results of the Optic Neuritis Treatment Trial.14,37 Treatment regimens Standard practice is to use high doses of corticosteroids for a short time, followed by a gradually reducing dose for a variable period of time. The optimal doses and treatment schedules have not been determined in clinical studies. A typical regimen is 500 to 1000 mg methylprednisolone i.v. each morning for 5 days, followed by 60 mg oral prednisolone every morning for a further 3 days, then the dose is decreased by 10 mg every 3 days until zero is reached. The reducing oral dose appears to prevent immediate relapses after discontinuing treatment.14 Adverse effects Corticosteroids can cause a wide range of adverse effects. The frequency and severity of these effects increases with the dose and duration of therapy.31 Generally, the short courses of corticosteroids used for treatment of MS exacerbations produce a low number of serious adverse effects. Minor effects often occur, but are usually transient. These include slight reddening of the face, a metallic taste during i.v. infusion, elevated mood, mild depression, anxiety, insomnia and indigestion. More serious adverse effects, such as acute psychosis, attempted suicide, cataract, necrosis of the femoral head and cardiac arrhythmias, have been reported in studies of very large doses (e.g. 2 g methylprednisolone daily for 10 days).11 Current and future MS practice Although there is a clear benefit from corticosteroids in acute exacerbations, many neurologists reserve them for severe exacerbations that are having a significant effect on activities of daily living. Some also restrict the number of courses to no more than two per year.22 The recent results of the Optic Neuritis Treatment Trial may increase the usage of i.v. corticosteroids in optic neuritis and other episodes suggestive of early MS. The results also re-open the question of whether intermittent corticosteroid therapy can favourably influence the course of MS. And they have called into question the value of oral corticosteroids.32,37
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Supportive careMS is a complex disease with a prolonged course and the potential to cause significant disability. The disease places heavy demands on medical, social and voluntary services, as well as on the patient's family. In order to provide the optimal management of MS patients, a multidisciplinary approach is required, involving a wide variety of health-care professionals. The broad term supportive care includes counselling and rehabilitation, which are described below. Counselling A diagnosis of MS is distressing as many people believe that the disease inevitably causes severe disablement and confinement to a wheelchair. Counselling and emotional support are therefore vital for sufferers and their families, and should be provided on a long-term basis.38 Aim of counselling The aim of counselling is to help people with MS and their relatives to understand and come to terms with the disease, and to plan and manage their lives. Counselling in MS should provide patients and families with:
Provision of counselling services Counselling services are provided by a wide range of personnel including nurses and clinical psychologists. Various organizations also offer counselling services. These obviously differ from country to country, but include charitable organizations specifically for disabled people and national MS societies. MS societies can provide information about the disease and about services and resources available to MS patients and their families. They often have a network of local MS groups that meet regularly and give patients the opportunity to discuss their problems. The International Federation of Multiple Sclerosis Societies (IFMSS) coordinates the activities of MS societies throughout the world. Rehabilitation Aim of rehabilitation The aim of rehabilitation is to reduce the impact of disabling and handicapping conditions. This is achieved by providing patients with the knowledge and skills needed to achieve and maintain optimal physical, psychological and social functioning. It improves the patient's quality of life and decreases the cost of the disability for the patient and society. Rehabilitation in MS Rehabilitation of the MS patient must be individualized because of the varied manifestations of the disease. Each patient should undergo a comprehensive assessment so that rehabilitation can be tailored to their needs.14 Because the future course of the disease is uncertain, the level of rehabilitation should be higher than is currently required, so that patients are able to maintain optimal function as disability progresses.39 Some of the most important elements of rehabilitation are outlined below. Physiotherapists are concerned with the management of all aspects of motor function. In MS, physiotherapists play an important role in the treatment of spasticity and ataxia, and help to prevent the development of secondary handicaps such as contractures, deformity and postural abnormalities. Physiotherapists educate MS patients about the benefits of physical exercise, and develop appropriate, balanced exercise programmes that can be included as part of daily life. In addition, physiotherapists are able to supply walking aids where necessary. Occupational therapy Occupational therapists are primarily concerned with helping patients to perform activities of daily living. They help patients and their families to devise daily schedules that will conserve energy for essential tasks and minimize fatigue. They assess the need for, and provide, aids ranging from wheelchairs to simple devices to help perform everyday tasks. For example, specialized cutlery is available for patients who have difficulty handling food because of spasticity, tremors or ataxia. When mobility is limited, occupational therapists assess a patient's need for home adaptations (such as bathroom rails, stair lifts, ramps and home extensions) and where relevant, liaise with housing departments and architects. Speech therapy Speech therapists assess and treat patients with speech, language and swallowing disorders. These often occur in MS, and range from slight communication difficulties to severe problems with swallowing. Speech therapists show patients how to use techniques and training exercises to help alleviate some of these problems. They can also provide communication aids, such as portable voice amplifiers. Social services MS patients and their families require many different types of social support, which is usually coordinated by social workers. Social workers may help with the provision of day care, help in the home, respite care and holidays. They also provide accurate information about the benefits and entitlements that are available, and help patients and their families to obtain them. Other services Many other organizations and services may be involved in the rehabilitation of the MS patient. They include:
MS centres In some countries, specialized MS centres have been established. These centres offer a full range of rehabilitation services, and provide the opportunity of a short stay during which the global performance of a patient can be improved.40
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Bu sayfadaki bilginin en son güncellendiği/doğrulandığı tarih:11/09/2001 |
Ana sayfa | Bağlantılar | Kayıt ve geri bildirim | Sözlükçe | Arama motoru ve site haritası | Yerel Bilgiler | Yardım| Bir arkadaşa söyleyin | Sorumluluk almama | Basın Bilgileri | Schering |
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