Multiple Sclerosis: 10 Things Primary Care Providers Need to Know Now

1. MS is a progressive disease so it is critical that patients adhere to the disease modifying agent (an injection, an oral or intravenous medication) and follow-up with their MS team regularly.

2. Understand the effects of the new emerging MS therapies, which may suppress the immune system and lead to infections or change the immune system in a way that may increase the risk of malignancy. Don’t underestimate the importance of monitoring blood tests, such as complete blood cell counts, blood chemistry, and liver profile.

This is an MRI of the brain and spinal cord of a patient with multiple sclerosis of 10 years duration who recently transitioned from a relapsing-remitting course to a secondary progressive course. The FLAIR imaging of the brain shows confluent disease typical for MS, with periventricular and juxtacortical lesions. The spinal MRI shows a lesion in the cervical cord, which is commonly seen in MS. [Images courtesy of Aliza Ben-Zacharia.]

3. Learn the correlation and the paradox of no correlation between MS disease progression and the MRI presentation. Moreover, understand the correlation between MS symptoms and lesions in the spinal cord that usually lead to loss of function.

4. MS symptoms may fluctuate intermittently and patients may have bad days or good days. This does not mean that their disease is progressing. Increased body temperature due to stress, exercise, or illness sometimes will exacerbate patients’ symptoms temporarily (called Uhthoff’s phenomenon).

5. MS symptoms may create a vicious cycle; you may therefore need to treat original symptoms that cause other symptoms. For example, you may need to address fatigue that may lead to cognitive dysfunction or depression.

6. Not all symptoms are related to MS; check for other causes for the symptoms. For example, patients may be fatigued because of hypothyroidism or anemia.

7. Treat the symptoms with non-pharmacological agents first and then use medications. Refer the patient for rehabilitation and employ other modalities to maintain optimum function and wellness. 

8. Always minimize the risk of infection, which can trigger an MS attack. It may be a pseudorelapse or a true relapse. An infection can trigger a true relapse, which requires treating the infection and the relapse simultaneously while monitoring the patient. Patients often have increased symptoms during the infection and return to their baseline after the infection is treated: this called pseudorelapse. Pseudorelapse often occurs with increased stress or exercise and is sometimes related to high fever. (Symptoms in pseudorelapse are related to Uthoff phenomenon.) 

Since infections may trigger a true relapse, we recommend that patients receive a flu shot (not the mist) and Pneumovax vaccine if they are at risk (elderly, asthma, etc). “Live” vaccines are not usually recommended, but it is important to discuss future potential required vaccines with the MS team (eg, risk vs benefit if the patient is traveling to an undeveloped country where vaccination is required).

9. Reinforce the importance of a healthy balanced diet and exercise. Advise the patient to gradually increase exercise and activities while cooling body temperature (drinking cold/ice water or using cooling devices).

10. Refer for psychological counseling if patients present with psychosocial/emotional symptoms (common in MS secondary to biochemical changes in the brain, lifestyle changes, and effects of medications).

For More Information
• Agosta F, Pagani E, Caputo D, Filippi M. Associations between cervical cord gray matter damage and disability in patients with multiple sclerosis. Arch Neurol. 2007;64:1302-1305.
• Bastianello S, Paolillo A, Giugni E, et al. MRI of spinal cord in MS. J Neurovirol. 2000;(suppl 2):S130-S133.
• Bitsch A, Bruck W. MRI-pathological correlates in MS. MSJ. 2001;8(3):89-95.
• Fillippi M, Rocca. MRI evidence for multiple sclerosis as a diffuse disease of the central nervous system. J Neurol. 2005;252(suppl 5):V/16-V/24.
• Hyland M, Rudick RA. Challenges to clinical trials in multiple sclerosis: outcome measures in the era of disease-modifying drugs. Curr Opin Neurol. 2011;24:255-261.
• Neema M, Stankiewicz J, Arora A, et al. MRI in multiple sclerosis: what’s inside the toolbox? J Am Soc Exp Neurother. 2007;602-617.
• Pender MP. The pathogenesis of primary progressive multiple sclerosis: antibody-mediated attack and no repair? J Clin Neurosci. 2004;11:669-692.