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Corticosteroids were the first drugs tried to treat the relapses symptom in 1960's followed by variety of immune suppressing agents like cyclophosphamide, cyuclosporine, azathioprine, methotrexate and glatiramer acetate. (5) These drugs were not effective to reducing the symptoms but made useful platform for the developing tools for further studies in immunomodulation and explored the development of non-invasive monitoring methods in 1980's.(4)
The Launch of Magnet resonance imaging (MRI) made easy to visualise the brain and spinal cord to quantify the lesions in people suffering with MS. (4) Ian Young had predicted the value and suggested that MRI technique will help to measure the condition of MS and tried to evaluate the therapeutic regimens effect on MS.(6) In 1986 Robert Grossmann improved the MRI technique and discovered gadolinium enhancement as a marker of inflammation to detect the newly formed lesions.(7) And MRI technique was established for monitoring disease prognosis in clinical trials.
Interferons have been used in the history of developing drugs for the studies of man preceded animal studies. Interferon gamma can provoke accurate exacerbation of multiple sclerosis was found in early clinical trials, but was not show much important in treatment because of severe side effects, then interferon beta came in light as they can inhibit interferon gamma and they were well tolerated compared to interferon alpha. The importance of interferon beta came to publication in 1993 and was started to use as therapy, and was introduced in the form of interferon beta -1b in USA as the first proven effective therapy for relapsing remitting MS (8,9), and showed that they can be used for the treatment of secondary progressive MS in a study conducted in Europe(10).
New ways of finding therapies
The studies in the treatment of MS was challenging as many promising agents failed in the experimental treatments. But the classification of MS in to different forms played important effect in clinical trials conducted for MS. The trials were included blinding, randomisation, and selection of subjects made better outcome. (11).
Present day treatments
The present day treatments are managed to give individually or combined to the patents for effective results. They are classified and given as per the symptoms of the patents to reduce the symptoms or to modify the disease course.
1. Disease modifying agents.
Disease modify agents reduce the progression of the disease activity in people relapsing from MS and people with SPMS disease.
FDA approved drugs for modifying disease course
Interferon beta-1a is avlable in different names like Avonex, Rebif.
Interferon beta-1b is avlable as Betaseron, Extavia.
And mitoxantrone as Novantrone, fingolimod as Gilenya are used
2. Treating Exacerbation
When the disease is sever and attack last for more than 25 hours to week and impacting the ability to do basic functions then high dose of Corticosteroids are used to decrease the inflammation.
Corticosteroids used for treating MS
3. Managing symptoms
Symptoms of MS are different at time to time in one person and vary in each individual from mild to severe and they are managed mostly by strategies by proper medication, rehabitation of speech/language and using assistive devices.
Complementary and Alternative ways of treating MS
Many complementary and alternative ways are used by many people suffering with MS like dietary supplements, acupuncture, yoga which are from different traditions. These ways or medications do not have any scientific studies but still many people believe in them.(1)
There are many drugs in the clinical trials stage which can give a better support to improve the symptom of the people suffering with multiple sclerosis.
All the present available drugs are well tolerated but the effect of the drugs are for very limited period. The strategies for better efficacy are being made one of which is combination therapy. Several results of combination therapy have been published recently and many are still ongoing.(12)
Combinational therapy in treating many other chronic diseases like cancer, immune disorders like rheumatoid arthritis and hypertension have been proved very effective (13). The study on combined therapy of methotrexate and adalimumab for rheumatoid arthritis has made the therapy stranded for rheumatoid and for other tissue damaged conditions. (14) .studies in combination therapy using corticosteroids have been made, they have large impact on immunological conditions and as corticosteroids are used to treat in recovery of relapse condition MS the combination of them to treat MS will be very effective. (15)(16)
The combinational therapy is very intresting and shows positive hope for MS patents but the studies has to more specific to know the inter-action of the drugs which are been combined to treat as the they may have long delay effects.
New oral drugs
Many promising oral drugs are in trial stages which have potential to treat people with MS more effective than the present drugs
Fingolimod is a oral drug with a novel mechanism, which is currently in a phase III study, in phase II study, half year of the study in 281 patients with RRMS given orally with doses of 1.25.and 5 mg reduced inflammatory activity significantly when measured by MRI and clinical relapses. The reduction in activity showed 80% compared to patients on placebo, and showed 50% in 6-moth annualized relapses rate at two doses 0.35-0.36 compared to 0.77 with placebo. (17) The placebo controlled subjects entered the dose dose-blinded for 18-months phase and subjects treated with fingolimod were continued with treatment. The common side effects were dose dependent transient arrhythmias in a hour of first dose, increased arterial blood pressure and breathing problems.
The positive results made fingolimod in to further studies as an oral treatment option with assessing the afficacy for dose of 1.25 mg and alower dose of 0.5 mg in currently ongoing Phase III studies. (17)
The mechanism of action of fumaric acid (FA) is and how it exerts its effects is no known but it helps to deviate the induction of immune, by the deviation of interferon gamma producing autoantigen-specific Th 1 cells into an Interleukin-4 dominated Th2 phenotype. (18)(19)
Fumaric acid's most common adverse effect in Phase I clinical trial were flushing, pruitus, gastrointestinal disturbance, myalgia, dizziness and headache.
Study in 257 RRMS patients with placebo controlled double blind, randomised phase II was conducted, the first year study was planed in two phases, a 24-week,double-blind, placebo-controlled, to know safety and efficacy and followed by 24 week, dose blind, safety extension phase. The subjects who recived placebo has been given active drug in second phase, a 69% reduction in mean number of lesions has been found in patents given 240 mg TID of FA compared to patents given placebo, And 48% reduction showed when measured in MRI. Although the study was not evaluate the effects of FA but it showed the efficacy in end points to treat annualized relapses rate .(20)
The most common adverse effects were headache, diarrhoea, upper abdominal pain and hot flush.
Some more promising drugs like cladribine, teriflunomide, laquinimod are in undergoing studies, but the fate of these drugs mainly depends on the safety profile to make in to first line of drugs.
The studies and facts show that multiple sclerosis