Let us continue to talk about some issues which arise during the treatment of multiple sclerosis.

1) How does the disease pan out: Let me try to give you a broad overview of what to expect if you have been diagnosed with multiple sclerosis. I want to stress that this by no way applies to every patient, because each patient’s disease behaves in its own unique way. Initially as I stated earlier, multiple sclerosis has a remitting and relapsing course. You have an attack, it causes some deficits (weakness, numbess, vision loss or gait and balance problems) and then the attack remits and patient may come back to his or her baseline functioning (meaning there are no residual deficits left behind). When multiple sclerosis behaves in this manner it is said to have a relapsing and remitting course (RELAPSING AND REMITTING MULTIPLE SCLEROSIS OR RRMS).

As the disease progresses though and the patient continues to have more attacks, it is seen that the patient does not remit or revert back to the baseline (meaning that some deficits are left behind like some residual weakness or numbness, some problems with balance, tremors etc). When this occurs the patient starts to incur some disability and the disease is said to enter a progressive course (SECONDARY PROGRESSIVE MULTIPLE SCLEROSIS OR SPMS).

As I stated earlier patients in SPMS stage start to get disabled whether it is due to excessive weakness, fatigue or problems with balance or a disabling tremor. As doctors we try to grade their progression in this stage and there are various scales we use. One of the most commonly used scale is the Expanded Disablility Status Score or EDSS. This is a 10 point scale and when a patient reaches midway like around 5 to 6, he or she starts to need assistance with walking and further on may need a wheelchair for ambulation.

The intention behind using the interferons and other immunomodulatory drugs like copolymer (Copaxone) is to prevent or rather delay the progression from a RRMS to a SPMS.

Hence the rationale behind treating all patients aggressively from the onset. Once the patient is in a SPMS state, the medications are continued and different medications might be added to try to halt and delay the disease progression.

Till now we do not have any drugs which change the natural history of the disease (meaning cure it!!), all we have are medications which may delay the progression.

 There are a certain subgroup of MS patients who have a progressive downhill course right from the onset of the disease (meaning in them the disease does not follow a relapsing and remitting pattern rather they continue to incur more and more neurological deficits). These patients as you can imagine have a poorer outcome and this pattern of disease progression has been referred to PRIMARY PROGRESSIVE MULTIPLE SCLEROSIS OR PPMS