MULTIPLE SCLEROSIS TREATMENT

Liječenje multiple skleroze se osobito tijekom posljednjeg desetljeća intenziviralo te obuhvaća liječenje osnovne bolesti imunomodulacijskom terapijom i primjenu simptomske terapije za redukciju popratnih simptoma. Imunomodulacijsku terapiju multiple skleroze čine interferon beta-a1 (Avonex, Rebif), interferon beta-1b (Betaseron, Extavia), peginterferon beta- 1a (Plegridy), glatiramer-acetat (Copaxone), mitoksantron (Novantrone), terifl unomid (Aubagio), dimetil fumarat (Tecfi dera), fi ngolimod (Gilenya), natalizumab (Tysabri), alemtuzumab (Lemtrada), daclizumab (Zinbryta) i ocrelizumab (Ocrevus). Lijekovi se prema redoslijedu primjene dijele na lijekove prve, druge i treće linije. U liječenju bolesnika teži se postizanju koncepta NEDA („No Evidence Of Disease Activity“) čiji ciljevi su da nema relapsa, nema povećanja onesposobljenosti, nema novih ili aktivnih lezija na MR slikama, nema znakova atrofi je mozga. Postizanje cilja NEDA podrazumijeva ranu dijagnozu, ranu primjenu indiciranog lijeka uz mogućnost zamjene terapije učinkovitijim lijekom. U kliničkoj praksi se trenutno provode dva različita terapijska pristupa: eskalacijski i indukcijski. Eskalacijska terapija uključuje rano započinjanje primjene prve linije imunomodulacijske terapije te ako su lijekovi djelomično učinkoviti ili neučinkoviti brzi prelazak na drugu liniju liječenja. Indukcijska terapija uključuje ranu upotrebu imunosupresivnih lijekova nakon koje slijedi dugoročna terapija održavanja imunomodulacijskim lijekovima. Sigurnosni profi l lijekova za indukciju ukazuje na potrebu stratifi kacije rizika i pažljivu selekciju bolesnika.Introduction: Lately, treating multiple sclerosis is becoming ever more challenging. It includes a combination of immunomodulatory and symptomatic treatments. There is an expansion of immunomodulatory agents, especially monoclonal antibodies. New drugs to treat relapse-remittent multiple sclerosis (RRMS) and a drug for primary progressive multiple sclerosis have been introduced. Also, a new concept of treating, named No Evidence of Disease Activity (NEDA) appeared with an aim to achieve a patient that is free of relapses, free of new EDSS deteriorations, free of new or newly enlarged lesions on magnetic resonance imaging, and free of brain atrophy. It would encompass early diagnosis, early therapy implementation, and the possibility of therapy changing. To achieve NEDA, two approaches are available, escalating and induction therapy. Escalating therapy includes the use of fi rst-line drugs with the possibility of changing to second-line agents in case of therapy failure. The induction therapy approach considers induction with immunosuppressants followed by maintenance therapy with immunomodulatory agents. Aim: Our aim was to search through scientifi cally published papers for medically valid data in order to provide the best medical advice for both physicians and patients in search for appropriate treatment. Methods: We performed extensive MEDLINE search, dating from 1993. Results and Discussion: The interferons, glatiramer acetate, terifl unomide and dimethyl fumarate are considered as the fi rst-line RRMS therapy, while other available medications represent second- or even third-line therapy. Avonex, Betaseron, Extavia, Glatopa and Copaxone can be utilized as an early treatment of clinically isolated syndrome. Ocrelizumab is a monoclonal antibody used to treat primary progressive form of multiple sclerosis. Secondary progressive multiple sclerosis can presumably be treated with interferon beta, terifl unomide, fi ngolimod, alemtuzumab and dimethyl fumarate while they express an effect on disease activity control, otherwise mitoxantrone is another option available. Conclusion: The goal would be to collect as much data as possible and re-evaluate all relevant data on multiple sclerosis immunomodulatory therapy that does not include monoclonal antibodies. Also, the goal would be to notice adverse effects and special recommendations on pre-treatment concerns, as much as control of certain parameters during and after the application of disease modifying agents. The best approach to patient management is through multiple sclerosis centers where interdisciplinary team can effectively resolve all the concomitant events