What is Multiple Sclerosis?

Multiple sclerosis or MS is a disease affecting nervous system, mostly brain and the spinal cord. The term sclerosis means hardening; in this case hardening of an area of brain or the spinal cord. This term originated in old days when no imaging (like CT scan or MRI) was available to visualize brain. In those days, a lot many brain autopsies were performed to find out causes of disease. Normal or healthy brain tissue was quite malleable, like a soft jelly. The area affected by this disease looked different, and somewhat hardened and cheese like when compared to the area around it. In a well-established patient, one usually finds multiple such areas and so the term of multiple sclerosis. Nowadays, we can see these areas in a live patient with CT scan but more clearly with an MRI.

 

What causes hardening or sclerosis of brain in Multiple Sclerosis?

Evidence suggests that it is due to an inflammatory reaction, with involvement of body’s own immune system. So, it is an autoimmune type of inflammatory disease of the central nervous system. It is not precisely known what exactly triggers this reaction to start with. Inflammatory reaction leads to release of different chemicals and recruitment of certain cells, which leads to destruction of surrounding tissues and neurons (degeneration). Hardening or sclerosis is like a scar, the aftereffect of this inflammatory response.

 

What is known about the inflammation in Multiple Sclerosis?

Central nervous system is a protected place, and it is mostly kept isolated from the immune cells of our body. Immune cells, like T cells and B cells, are part of the defense our body has against any hostile agents. To be on the safe side and because of its critical nature, immune cells that could build an attack against its own nervous system (auto-reactive cells) are destroyed soon after birth. But, according to our understanding, some of those cells in some people escape this process and continue to reside in the body. Nothing happens if these cells remain isolated and dormant, but in some people (may be due to some genetic factors) and due to some environmental factors, these cells get activated. They travel to the nervous system and start an inflammatory process against it, resulting in its destruction or degeneration.  This subject is quite complex and mostly understood by physicians primarily involved in this subject. Treatment for MS are designed to alter different aspects of this inflammatory response.

 

Is Multiple Sclerosis a new disease?

Though MS became better known in late 1800s, cases have been described in literature in 1300s, which likely suffered from this condition. It was likely there even before that time.

 

Who is at risk for Multiple Sclerosis?

Based upon statistical analyses, few factors are noted to be more common in patients with MS.

1. Living in Northern hemisphere, which probably is due to associated other environmental risks, e.g., limited sun exposure.
2. Limited sun exposure: Exposure to ultraviolet B (UVB) exposure in childhood, more so in areas with higher exposure to sun, seems to be protective.
3. Vitamin D deficiency: It is associated with risk for MS, but taking vitamin D supplements has not clearly shown any benefit.
4. Ethnicity: Traditionally, Caucasians were thought to be more affected. But more extensive studies have found that other ethnicities, African American or Hispanics, or other races living in Northern hemisphere were equally or even more affected.
5. Gender: Women are much more affected than men.
6. Genetics: Though no one gene is known to cause MS, some genetic basis for its risk have been identified. There is no significant reason to check for these gene abnormalities during routine clinical practice.
7. EBV infection: There is some suggestion that exposure to viruses like Epstein-Barr, CMV, and HSV and increase risk for MS.
8. Smoking: Smoking tobacco increases risk of MS but chewed tobacco does not.
9. Obesity: Obesity is a risk factor especially in women and children.
10. Gut microbiome: This issue has become better known in recent decades and there probably is a relationship between certain type of bacterial colonies in the gut and risk of MS. But its exact nature has not been well defined. At this time, it is difficult to say that one type of diet is more protective than other, though diet with limited natural fiber, complex carbohydrates, or constipating diet may worsen MS symptoms.

 

What are the symptoms of Multiple Sclerosis?

Symptoms of MS depend upon the area of brain or the spinal cord involved. Its symptoms are similar to symptoms of stroke, but they appear slowly and gradually. Common symptoms are one-sided weakness, numbness, double vision, blurred vision, difficulty walking, and difficulty talking. Other commonly noted symptoms are neuropathic type of pain, fatigue, forgetfulness, problems with urination, and cognitive problems.

 

How is Multiple Sclerosis diagnosed?

A single definitive test to diagnosis MS is not available. The diagnosis of MS is made based upon set of symptoms (sometimes with history of repeated attacks), findings on physical examination, and certain findings on MRI of brain (or the spinal cord).  In many patients spinal fluid is analyzed to look for a certain pattern of abnormalities. Another test called Evoked Potential screen helps to analyze functioning of different parts of the nervous system. There is no blood test for MS, but blood may be analyzed to rule out certain conditions that may look like MS.

Neurologists use a criterion to avoid missing any case with MS while at the same also avoiding overdiagnosis (false positive). For MS to be diagnosed, neurologist must be certain that patient’s symptoms are consistent with the diagnosis, and laboratories, especially MRI scans reveal findings confirming the diagnosis, as there are many conditions that may look like MS.

 

How easy or difficult is it to diagnose Multiple Sclerosis?

As stated above, there is no single test that may diagnose MS. For example, it is easy and straightforward to diagnose someone with HIV disease with a simple blood test. Diagnosing MS is different; it is achieved by collecting a complex set of data (history, examination, imaging, and other tests) and its analysis to reach a likely conclusion. In many cases presenting with typical history and well-established MRI findings, it is an easy diagnosis to make. In many others, when history is not clear-cut, examination findings are lacking, and MRI findings are equivocal, it is not an easy diagnosis to reach. This is the reason that neurologists sometimes talk in terms of “possible MS,” or “probable MS.” Many times, this lack of clarity in making diagnosis is a source of frustration for the patient.

 

What is the role of MRI scan in diagnosing Multiple Sclerosis?

As described above, the main feature of this disease is hardening or scarring or sclerosis of the brain and/or the spinal cord. MRI can help us visualize it. In fact, modern MRIs can help us visualize it even before it gets permanently hardened or scarred. But one has to be careful analyzing images of MRI. It can help us visualize scarring of brain but it does not specifically indicate if it is from MS or any other condition. Many other conditions are known to cause somewhat similar MRI abnormalities of brain, such as strokes, infection, inflammation from other causes, and rarely cancer. Radiologists and neurologists use a technique called pattern-recognition when analyzing the lesions to reach the most likely impression.  Many times this analysis is straightforward, and in many other cases, it is equivocal (indicating multiple possibilities).

 

What is the role of biopsy in diagnosis of Multiple Sclerosis?

Generally speaking, biopsy is not used in diagnosis MS. Brain and the spinal cord are special organs for which biopsy is avoided as much as possible. Probably the only time biopsy helps to make a diagnosis of MS is when a patient’s MRI suggests a brain tumor. A biopsy is done to rule out tumor, and instead it may turn out to be MS.

 

What is the role of cerebrospinal fluid (CSF) analysis in Multiple Sclerosis?

 CSF analysis is frequently a part of MS diagnostic workup, though not every patient needs it. Our brain and the spinal cord have cavities in the center, where CSF circulates. It circulates inside these cavities and then out on the surface of the brain and the spinal cord. Because of its closeness to the brain structures, it provides significant information about brain diseases. It can be accessed either directly in the brain, in the neck, but more commonly from the lower back, which carries minimum risk. Spinal fluid looks like clear water but it has certain amount of sugar, protein, and cells. In a condition like MS, protein level may be higher, there may be more white cells than normal, and more importantly it may have some exclusive proteins (antibodies) not present in the blood, implying an inflammatory process localized in the brain. For comparison, protein analysis is done on both blood and spinal fluid samples taken together. It is important to mention that there is no specific finding in CSF that is exclusive to MS. CSF findings may only suggest an inflammatory process exclusive to the brain, or the spinal cord.   

 

What is the role of Evoked Potential screen for diagnosis of Multiple Sclerosis?

Evoked potential test is a physiological assessment of the functioning of nervous system. For example, while an image shows us physical integrity of the spinal cord, Evoked Potential test can reveal integrity of messages traveling through it. Different parts of the nervous system are stimulated in different manner. Visual pathway is checked by exposing eyes to a flickering checkered screen, hearing pathway by exposing ears to tunes of different frequency of noise, and the sensory pathways by sending an electrical signal through the spinal cord from arms and legs. A computer keeps track of the signal from exposure to its destination in the brain. To avoid artifacts from unrelated signals, stimuli are sent numerous times and an average tracing is taken, which helps to cancel out the “noise.” This method can detect and localize minor disruptions in the signal pathway. This is a non-specific test, i.e., it can detect and localize a disruption but cannot give information about its cause. Though, utility of this test has declined after availability of imaging methods, it is still a useful tool in selective cases.

 

What is optical coherence tomography (OCT)?

It is a measurement of retinal nerve fiber layer thickness performed by an ophthalmologist. Like a brain MRI, it helps determining progression and disability in MS, especially of visual type.

 

What is serum neurofilament light chain level?

It is a blood test that may be useful for prognostication purposes in MS patients. It is not widely used so far due to multiple reasons including its availability, cost, and reliability.

 

What are different types of Multiple Sclerosis?

 Types of MS are mainly defined based upon their clinical features. Following are some of the common types

A: Benign MS: There is a set of patients who may have MS but their clinical coarse is so mild or unnoticeable that they barely have any symptoms. It is not a diagnosis one is able to make at the start of the disease or in young age. It is rather a retrospective description of patient’s condition. It is also not clear which of the patients diagnosed today may have this course.

B: Malignant MS: This is the other extreme when a patient develops a rapidly progressive severe form of MS resulting in severe disability or even COMA.

C: Relapsing MS: This is the more common type of MS. Its main feature is an exacerbation or an “attack” of MS when patient develops new set of symptoms that last for days to weeks followed by a period of relative remission. After an interval of weeks to months in remission, and sometimes years, another attack may happen followed by another remission. Though patient may go into remissions, some residual symptoms or effects usually persist. If this pattern continues, patient is at risk of developing physical and/or mental disability. Age of onset is earlier, 20s-30s, and women are more affected than men.

D: Primary-progressive MS: This is the type of MS where there is no particular “attack” of MS. Symptoms develop insidiously and in a progressive manner. Over months to years, patient slowly develops physical and mental disability. Age of onset is little bit later, around 40s, and both men and women are equally affected.

E: Secondary-progressive MS: This is when a patient starts with a clinical course similar to remitting-relapsing MS, but after a certain period further progression is similar to the primary-progressive type of MS, i.e., progressive but without any further attacks.

 

Why it may be important to know the type of MS?

Defining the type of MS helps to determine its expected clinical course. It also helps to figure out the right type of treatment plan. Most MS treatments are designed for the common remitting-relapsing type of MS and may or may not be effective in some other types.

 

Is there a cure for MS?

At this time, there is no cure for MS. Multiple treatments are available that may slow down the disease, and delay or prevent physical and mental disability. In reality, for most patients, disease continue to progress in spite of treatment. Treatment with stem cells may be a promising alternate choice for at least some patients. A small study of stem cells treatment has suggested almost complete remission of MS. More research is needed to figure out how this type of treatment may be an option for larger group of patients.

 

What type of treatment is available for Multiple Sclerosis?

Medicines are available that seem to tweak patient’s immune system in a way to slow down or stop the inflammatory process of MS. The commonly used term for this type of medicines is an immune-modulating agent. They are also called disease-modifying agents. There are numerous such drugs to choose from; some are skin injections, others are oral tablets or capsules, and some others are intravenous infusion type of injections. They may differ in terms of their efficacy or strength, and their side-effect profile or risks. None of them are cheap, but some are way more expensive than others. On top of that, insurances may prefer to provide one medicine instead of another.

Following is most of the immune modulating or disease modifying medicines used for MS. I have put them in groups for understanding based upon their efficacy (strength) or risks (adverse effects). This grouping is over-simplification and a general guide and may not address peculiarities of each medicine:

• Mildly effective and relatively safe: In this group are interferons (e.g., Betaseron) and glatiramer acetate (e.g., Copaxone).
• Mild to moderately effective but with more risks: Teriflunomide (e.g., Aubagio), ozanimod (Zeposia), and ponesimod (Ponvory).
• Moderately effective with lesser risk: Dimethyl fumarate (Tecfidera), diroximel fumarate (Vumerity), monomethyl fumarate (Bafiertam).
• Moderately effective with moderate risk: Fingolimod (Gilenya), Siponimod (Mayzent)
• Moderate to best with higher risk: Ocrelizumab (Ocrevus), Ofatumumab (Kesimpta), alemtuzumab (Lemtrada), Cladribine (Mavenclad).
• Best efficacy so far but with even higher risk: Mitoxantrone (Novantrone), Natalizumab (Tysabari).

 

Which treatment is the best for MS?

One may be able to answer this question if different treatments were tested in comparison to each other, but that type of testing is mostly not available. Most of the medicines are tested against a placebo treatment. In recent years, it is considered unethical to use a placebo as a comparison because many treatment options are available. So, the newer and any future treatment are compared to an already established type of treatment. Unfortunately, I note that the medicines used for comparison in this type of comparative trials are already proven to be weak, limiting the value of comparative analysis.

Where a comparison study is available, it is used to find the better of two treatments. Without a proper comparison study, physicians use other type of data to determine the efficacy or effectiveness of different medicines. They also compare side effect profile of medicines. Many of these medicines are in use for more than 10 years providing a large-scale collective experience. There is a general understanding that some medicines are more effective (or stronger) to control the disease than others. At the same time, it is also understood that some medicines can have more side effects or risks than others. 

 

How the decision is made to prescribe one treatment for Multiple Sclerosis over others?

There are four factors in the following order that a physician commonly uses to make this decision:

1. Patient’s drug allergies, or an inability to take a medicine (e.g., not able to take injections)
2. Efficacy or effectiveness of a medicine, idea is to pick the most effective medicine possible.
3. Side-effects profile or risks associated with a treatment, to pick the safest within a group.
4. Cost-effectiveness.

 

Ideally these should be the only factors a physician considering while making this decision, with more weight given to the first three factors. Unfortunately, though, there is another factor that may veto this decision-making process and tilt it towards a particular medicine, and that is patient’s insurance coverage. Neurologists and their patients struggle on regular basis while trying to balance all these factors while making these critical decisions.

 

What is the goal of treatment in Multiple Sclerosis?

With no cure available at this time, a treatment plan is used to limit further attacks or progression of MS, and prevent disability. None of the available medicines completely stop progression of MS, but they can make attacks a rare occurrence, or can significantly slow down its progression.

 

Are oral treatments as good as injections for Multiple Sclerosis?

Oral agents are not any different than injections in terms of efficacy and side effect profile, i.e., some are more effective than others, and some have more side effects than others. The real difference is their ease of being an oral treatment instead of an injection.

 

How long do I have to take a medicine for Multiple Sclerosis?

Presently available medicines for MS are given for long-term use, or for permanent use. Many times, if patient is stable for many years, or in later stages of life when the disease may calm down, and after weighing the risks and benefits, I consider stopping the medicine. Another reason to stop immune modulating agents with advancing age is aging and weakness of patient’s immune system, resulting higher risk for complications.

 

How often do I need to have a blood test while taking a medicine for Multiple Sclerosis?

This depends upon the type of medicine. Some medicine may not require any blood test at all, more than routine yearly blood tests. Many others may require close clinical monitoring, and frequent blood tests.

 

What drugs are useful in primary or secondary progressive type of MS?

Most MS drugs are used in the relapsing form of MS, which is most common type. Few drug options are available for progressive form. In this list are:

1. For secondary-progressive MS: Interferon beta 1-b, mitoxantrone, Siponimod, ozanimod, ponesimod, cladribine.
2. For primary-progressive MS: Ocrelizumab.

Many trials are undergoing for this type of MS and there may be more drugs available.

 

What is the treatment of fatigue in Multiple Sclerosis?

Fatigue is a common symptom in MS. It may be due directly to MS, or there may be other factors, such as sleep disorder, thyroid disorder, obesity and lack of exercise, depression, or diabetes. As far as specific MS fatigue is concerned, it may respond to brain stimulant drugs like methylphenidate or modafinil. They can be used on regular basis, or preferably on as needed.

 

Why patients have urinary problems in Multiple Sclerosis?

Urinary apparatus including kidneys, ureters, bladder, and urethra is a complex organ system that requires a detailed description to understand its functioning. Following is an overview:

Blood is filtered in kidneys and waste products are excreted in urine, which travels down through two tubes called ureters to the bladder. The bladder acts as a storage tank until it gets emptied. When empty, the bladder is like a deflated sac. As urine collects in the bladder it gets larger. When it is full, it sends a signal to the brain so that the person may empty it. In healthy young adults this may happen once bladder has about 250-500 cc of urine, depending upon the gender and size of the person. If for whatever reason the person does not want to empty the bladder, another signal from brain is sent to the bladder making it lax, and the urge to urinate disappears. After some more time and after the bladder has more urine, another cycle of signaling starts with a stronger urge to urinate. If the person still wants to delay urinating, brain may send another signal to the bladder, and it relaxes further. This continues until the person decides to urinate, or the bladder cannot relax any further and one has to urinate.

The process of urination is a sophisticated act or a reflex of which only a small part is in our control. Bladder is mostly made up of muscle tissue with its lower end shaped like a funnel. Around this funnel is another special muscle (internal sphincter) that keeps the funnel closed, like a clothe-pin, until urination. The bladder muscle and this particular muscle around the funnel are not in our voluntary control. Attached to this funnel is a tube called urethra that takes the urine out. There is another set of muscle around the urethra (external sphincter), which is in our control. Both the internal and the external sphincters have to relax before urine can come out. Usually the process of urination starts with a message from the brain when we decide to urinate and assume an appropriate posture. Abdominal muscles around the bladder contract to put pressure on the bladder, while muscles in the pelvis relax. The bladder muscle starts to contract and the internal sphincter relaxes. Urine comes down the funnel in the urethra and at that point we relax the external sphincter around the urethra. Other than making the conscious decision to start the process of urination, this act of relaxing the external sphincter is also in our control. Rest is a reflex. Once urination starts it is not easy to stop, until bladder is almost emptied. A problem with any of these structures may result in problem with urination, and the type of problem depends upon the structure affected. Following are some common examples, and in this list kidney and problem with ureters are not discussed, as they are generally not involved in MS:

A: Problem with bladder: Once inflated, the bladder muscle has the tendency to contract, which usually is suppressed or inhibited by signals from brain. If there is any disruption of these inhibitory signals from damage to certain areas of brain or the spinal cord, bladder starts to contract prematurely. A normal person may not have any urge to urinate until there is about 300cc of urine in the bladder. An out of control bladder may start creating an urge with much smaller volume. Patient may get frequent urges to urinate but the amount urinated is relatively small. This type of bladder is sometimes called spastic bladder or hyperactive bladder. Like any other muscle, and like a vicious cycle, staying hyperactive may lead to further build up of bladder muscle mass, which may result in decrease in its internal capacity to carry urine, and thus over time making the situation worse. Typical symptom of hyperactive bladder problem is frequency of urination with smaller than normal volume urinated. It is usually treated with a medicine to relax the bladder.

The opposite of hyperactive bladder is a bladder that is too relaxed, or atonic bladder. In this condition the bladder is usually large and has lost its muscle tone. This may happen after years of staying in a hyperactive form. This bladder cannot empty itself and for urination, one inserts a catheter inside the bladder on periodic basis.

B: Problem with Internal Sphincter: This is a clamp or a clothe-pin like muscular structure around the lower or the funnel part of the bladder ending in urethra. It keeps the bladder closed until it is ready to be emptied, and bladder cannot be emptied if it stays abnormally constricted or tight. In normal situations, bladder muscle and this muscle work together and in a synchronized manner. First the bladder contracts pushing urine down in the funnel, and then this muscle relax. Both of these actions are part of a reflex not in our control. In abnormal situations, bladder may contract but this muscle may not relax or relax well and the patient may not be able to urinate, or urinate well enough. Patient may get an urge to urinate but may have difficulty urinating. This may happen due to loss of higher control on these structures from damage to the spinal cord or the brain. It is not an easy condition to treat but fortunately is a relatively rare problem. It may also be important to know that this structure, the internal sphincter, and the external sphincter may be damaged in women during difficult vaginal labor, in which case it may not be able to hold itself tight and the patient may complain of frequent urination or stress incontinence or frequent urine leaks.

C: Problem with External Sphincter: This is a muscular structure around the urethra with the type of muscle that is in our voluntary control. By holding it tight, we can hold urine for a while even if the bladder is full and trying to empty itself. To urinate, we voluntarily relax this structure. If for some reason it is not relaxed, urination is restricted. Common reasons where there is difficulty relaxing this structure include infection, inflammation, interruption of signal from brain or the spinal cord, or sometimes from psychological reasons, such as extreme anxiety or fear. Treatment depends upon the cause.

 

Why women have frequent urinary infection (UTI) in MS?

Women are particularly at risk for frequent infection in urinary system, the so-called urinary tract infection or UTI. Reasons include a relatively small length of urethra, about 4cm compared to about 10cm in men, and its opening in a wet place. Other added issues may be obesity, damage to pelvic muscles or the urethra during childbirth, or the sexual activity. Depending upon these factors, all women are at higher risk for UTI. Proper genital hygiene may be the best approach for its prevention. Use water to clean instead of wipes, urinate and wash right after sexual activity, avoid tampons and use pads, avoid keeping a wet pad on for too long, thoroughly wash and/or shower after menstrual discharge is over, use probiotics or a serving of natural yogurt daily, avoid constipation, exercise regularly, and avoid obesity. Exercising pelvic muscles and the external sphincter helps, both men and women. This is done by the so-called Kegel exercises.

 

What is the treatment of pain in Multiple Sclerosis?

Pain specific to MS is called neuropathic pain. This is the pain caused by or associated with a malfunctioning nervous system. It may be severe facial pain from Trigeminal Neuralgia, headaches, or pain in limbs form damaged spinal cord. This type of pain is not easy to treat. Usual pain medicines or anti-inflammatory drugs do not seem to work for this pain. More effective medicines are the ones commonly used for epilepsy, but not every epilepsy medicine is useful. Opioids also do not provide consistent relief, and may result in added problem of drug-dependence.

Neuropathic pain is seldom in complete control. Medicine(s) may bring it to a manageable level. Also, certain symptoms like numbness do not respond to medicines. Patient education is important. Pain control is better if associated anxiety, depression, and sleep issues are managed well.

 

Does Multiple Sclerosis (MS) cause dementia?

Dementia or some elements of cognitive disorder is very common in MS. Compared to a healthy person, patients with MS have cerebral atrophy on brain imaging suggesting diffuse neuronal loss, which leads to cognitive dysfunction. Commonly observed problems are with memory, emotional stability, decision-making process, and spatial orientation. Depending upon where the MS lesions are, there may also be problem with vision, language and speech. Problem with vision or spatial orientation may result in confusion or auto accidents. Emotional lability may impact social relations, while many MS patients also have emotional indifference.

Diagnosis of cognitive dysfunction and dementia can be made using the similar clinical tools used for diagnosis of Alzheimer. Brain imaging does not provide much help for this diagnosis. There is no specific or effective medicine available at this time for dementia or cognitive problems from MS, other than treating MS itself. Medicines usually used for treatment of Alzheimer are sometimes used but their utility is debatable. It is important to rule out other treatable causes of cognitive problems including anxiety, depression, sleep disorder, and drug use, including alcohol and marijuana. Immune modulating therapy may also help to control or slow down cognitive decline.  

 

Is there a medicine for problem with walking in Multiple Sclerosis (MS)?

Difficulty walking is a common problem in MS. It may be from lack of control from the brain due to lesions in the brain, or lack of transmission of brain signals due to the lesions in the spinal cord, making legs weak and spastic (stiff). One may divide each of these categories into many others but that discussion is mostly academic. Pain and stiffness of leg and back muscle also contribute to this problem. A medicine, dalfampridine, may help with problem of difficulty walking. Some patients may also benefit from muscle relaxing medicines. In addition, regular strength, flexibility, and balance exercises may also help.

 

How to treat anxiety and depression in Multiple Sclerosis?

Both anxiety and depression are common in MS. Their overall treatment is like the treatment without MS. Unless it is properly managed, anxiety disorder may lead to the problem of over-diagnosis, especially over-diagnosis of MS exacerbation and over-treatment with steroids. It also significantly impacts quality of life, including social interactions. Counseling and medicines provide reasonable relief.

 

Does Multiple Sclerosis (MS) cause any sexual problems?

MS is mostly a young age disease with a potentially significant impact on patients’ sexual health. Additional psychological burden of stress, anxiety, and depression may make things worse. Some medicines used for treatment for one condition, like SSRIs, may fix one symptom and create another. Patients are recommended to discuss this issue with their doctors. They may benefit from counseling, adjustment of meds, and some specific measures or medicines. In general there is no contraindication to using medicines that are commonly used for erectile dysfunction. Sometimes just removing one medicine and changing it to a different one makes the whole difference.

 

Can I get pregnant with Multiple Sclerosis?

Patients with MS may have pregnancy, and healthy children. MS does not seem to impact patient’s ability to get pregnant, and in case of any difficulty, an infertility treatment can be undertaken with MS. It may just make the pregnancy somewhat more difficult, e.g., by causing more fatigue. Its impact may be different for different patients, depending upon the nature of physical and/or mental issues, and the medicines they may be taking. My usual recommendation to women in this regard is that if they are considering getting married or having children, they should not delay it too much. Risk associated with pregnancy increases in all later-age pregnancies. Also, the physical and psychological requirements of raising a child may be difficult to handle in later age.

Pregnancy is a special physiological state, and it is best to avoid any internal exposure (inhaling, eating, drinking, injecting, etc.) of all drugs, medicines, and artificial chemicals during pregnancy. Be careful about the so-called natural products too, not all natural products are safe just because they are natural. But some chemicals like prescribed vitamins or mineral, or medicines might be useful during pregnancy, and for some patients completely stopping prescription medicine(s) may not be a practical option. The next best thing is to fully understand the risks and potential benefits, and make an intelligent decision. It is best to plan a pregnancy and take appropriate steps to avoid any preventable complications. Preventive steps should start even before having unprotected intercourse, as once a pregnancy is known or diagnosed, many critical days of fetal neurological development may have already occurred.

The issue of risk-assessment of any medicine during pregnancy is usually dealt by collecting long-term data of patients exposed to a medicine. This type of data and its statistical analyses is not perfect but is still helpful. Looking at it in this manner, some immune-modulating MS medicines seem to be reasonably safe, while many others can be harmful to the growing fetus. With that said, the best approach is to discuss the issue of pregnancy with their doctor at least few weeks before having unprotected intercourse. This way there may be enough time to stop a harmful medicine to avoid any exposure to the developing fetus.

As far as labor or delivery is concerned, there is no particular or specific concern based just upon the diagnosis of MS. There may be concerns related to physical or psychological issues. Physical issues may be dealt by proper support during the pregnancy, and appropriate physical position during labor. An appropriate social-support network at home, and counseling may help with psychological issues. Breast-feeding is not a problem with MS, which is not a communicable disease. Breastfeeding is encouraged at least for a year due to its positive impact on the newborns’ wellbeing.

Pregnancy is a relative immune-compromised state, but the compromise is relatively selective, if not exclusive, for the fetus. Observational studies have suggested that patients may have lower activity of MS during later part of the pregnancy, and lower level of exacerbations. But if an exacerbation occurs, it may be treated.

 

Can patients taking MS meds can have vaccinations?

Vaccines are not contraindicated in MS. They can help minimize risk of infections and their complications. As far as for patients taking immune medicines for MS, following guidelines may help. Recommendation about this topic may change. 

1. No reason to delay or change treatment: Interferons, glatiramer acetate, teriflunomide, fumarates. Natalizumab.
2. Delay dose for 4 weeks after vaccines: Fingolimod, Siponimod, ozanimod, ponesimod, cladrivine, ocrelizumab, ofatumumab, alemtuzumab.

 

Can MS affect children?

Yes, it does. Children require a consultation with a pediatric neurologist. Unfortunately, pediatric neurology consultation may not be available in many places. Following is some information about children with MS:

• About 10% of MS presents in children, younger than 18 years.
• It is mostly of relapsing type.
• Diagnosis will require MRI scans and analysis of spinal fluid.
• There are some conditions mimicking MS in children that needs to be considered.
• Diagnostic criterion is similar to the one used in adults.
• Many of the same drugs used in adults can be used in children.
• Children respond to treatment better than adults.
• Left untreated, MS can cause disabilities including cognitive impairment.

 

Where can I find more information about Multiple Sclerosis?

American Academy of Neurology, AAN
National Multiple Sclerosis Society
Center for Disease Prevention and Control, CDC