Relapsing-Remitting Multiple Sclerosis
Though almost a million Americans over the age of 18 have been diagnosed with multiple sclerosis (MS), it's still considered a rare disease. And while relapsing-remitting multiple sclerosis may sound complicated, it's actually just the most common type of this uncommon condition.
Relapsing-remitting multiple sclerosis (RRMS) is an autoimmune condition that attacks the brain and the spinal cord—the body's "information superhighway"—and ultimately causes focal damage.
What are the symptoms?
"The autoimmune disorder manifests clinically by a relapse, flare, attack, exacerbation or neurological bout that happens for longer than a day," said Aaron Boster, M.S., a neurologist and founder of The Boster Center for MS.
Boster explained that multiple sclerosis generally presents in three ways. The first signs are a series of visible symptoms, ones you'll notice and describe to your doctor, starting with optic neuritis. With this condition, one eye starts to hurt when you move it and your vision goes blurry—these symptoms come on sub-acutely over hours or days. This is caused by inflammation in the optic nerve that, in turn, causes swelling, which creates a traffic jam of information traveling up and down the optic nerve, resulting in pain and blindness. Eventually, though, symptoms fade in the ensuing weeks and months, gradually getting better.
The second manifestation is transverse myelitis, the swelling of the spinal cord with everything below the swollen cord ceasing work. Numbness, tingling, weakness of the leg, bowel, bladder and sexual dysfunction are all symptoms.
The third and final manifestation of MS involves the brain stem. Symptoms include a droopy and/or numb face and double vision. The difference between this and a stroke is that it takes three steps to reach this point, whereas a stroke is the instant lack of blood supply that causes consequent death of cells.
"An MS attack is sub-acute and progresses over days and weeks," Boster noted. "The average age of onset is different, too: 60s for stroke, 30s for MS."
Causes and risk factors
The cause of multiple sclerosis is linked to a focal bout of inflammation on the brain or spinal cord that causes a short-circuiting effect on that part of your nervous system. With time, the inflammation dies down and you may regain some or all of your neurological function. As of now, the actual cause of MS is largely unknown.
"Some races and ethnicities are more likely to have the autoimmune response that causes RRMS," said Odelia Lewis, a family physician in Brooklyn, New York. Research indicates that MS occurs in most ethnic groups, including African Americans, Asians and Hispanics/Latinos, but is most common amongst Caucasians of northern European ancestry.
While the cause is still being researched, medical professionals point out that genetic predisposition plays a role, as well as environmental risk factors, such as morbid obesity, exposure to tobacco smoke, low levels of vitamin D and exposure to mononucleosis (mono). These factors are especially important if they occur pre-puberty.
According to John Hopkins Medicine, four times as many women have the disease as men. Relapsing-remitting multiple sclerosis is usually diagnosed when the patient is in their 20s or 30s.
A diagnosis of RRMS
Lewis said relapsing-remitting MS is diagnosed when a patient shows evidence of at least two separate areas of damage within the central nervous system (CNS), occurring on at least two different occasions. Common signs of CNS damage include fatigue, numbness, vision problems, spasticity/stiffness, bowel and bladder incontinence, and memory/cognition problems.
A brain MRI (magnetic resonance imaging) scan is usually performed to evaluate whether there are any corresponding lesions or plaques in the regions of the brain that correlate to the damage within the central nervous system.
Characterization of an MRI for someone with MS compared to other conditions is dramatically different. For example, a spinal tap is used less often. For the most part, most Americans with MS are diagnosed using clinical history, neurological examination, lab testing of blood and an MRI to confirm the final diagnosis.
Complications of MS and medications
RRMS has significant effects on both a person's lifestyle and livelihood, impacting relationships, their function in society and their ability to maintain employment.
RRMS patients experience pathological fatigue, which makes them twice as likely to experience depression and anxiety than the general population. Approximately 70 percent of persons diagnosed with some form of multiple sclerosis develop cognitive impairments.
This is not similar to dementia—where a person doesn't know who or where they are—but instead manifests in other ways, like an inability to multitask or maintain mental lists, or difficulty thinking quickly on your feet. After diagnosis, a care team will spend a lot of time helping MS patients manage their mood, energy and cognition.
Bowel, bladder and sexual function can also be dramatically impacted.
Relapsing-remitting multiple sclerosis is both a chronic and acute condition, and treatment plans are extremely individualized. Medications prescribed for acute attacks are usually fast-acting and aggressive so patients recover from symptoms quickly. For chronic conditions, the aim of the medication is to slow down the disease, helping reduce the number of attacks.
Prevention of acute attacks is the ultimate goal. One way to reach that end is disease-modifying therapy (DMT).
The most effective DMTs manipulate and suppress the immune system—which does carry the risk of infection, as well as changing how the body metabolizes drugs. DMTs not only modify multiple sclerosis by helping to prevent future relapses and disability, but also reduce inflammation as a result of modulating the immune system. The reduced inflammation leads to a reduction in symptoms.
As of now, there are 13 disease-modifying therapies for multiple sclerosis that have been approved by the U.S. Food and Drug Administration (FDA), seven of which are applied by injection, three orally, and three by infusion.
Symptomatic treatment is available for patients who still suffer from pain or discomfort after acute attacks. For example, an MS attack may present as burning in the leg—steroids can help reduce pain by 70 percent in this instance. The residual pain and discomfort from these attacks will not be crippling but they will affect their quality of life.
For acute attacks, a high dose of an anti-inflammatory drug like a corticosteroid can help hasten recovery. General treatment options for relapsing-remitting MS include intravenous monoclonal antibodies (rituximab), oral fumarates (dimethyl and monomethyl fumarate), oral SIP-1 modulators (fingolimod) and intramuscular or subcutaneous injectables (recombinant human interferon beta).
The greatest impact of relapsing-remitting multiple sclerosis is on a person's quality of life as the disease can affect mood, energy, cognition, and can worsen bowel, bladder and sexual function. Getting a correct diagnosis and settling on a comprehensive treatment plan is key, coupled with knowledge of the condition and the support of medical professionals and loved ones.