Multiple Sclerosis

Multiple sclerosis (MS) is a chronic neurological condition that affects the central nervous system (CNS), specifically the brain and spinal cord. The immune system mistakenly attacks the myelin sheath (a protective covering that surrounds the nerves), causing inflammation, scarring and disrupted nerve signal transmission. 

What is multiple sclerosis?

MS is a chronic autoimmune disease characterised by inflammation, demyelination, gliosis, and neuronal damage or loss [1, 2]. Depending on which part of the body the MS lesions are located, MS can present with a variety of neurological symptoms, which makes diagnosis and detection challenging. 

Types of multiple sclerosis

Clinicians typically classify MS based on the course of the disease [2]: 

• Relapsing-remitting MS (RRMS) – RRMS is characterised by episodes of attacks, followed by partial or complete recovery, referred to as remissions. Remissions can last weeks to years before another relapse. Over time, the period of remission may become shorter. Most (85%) MS patients present with RRMS at onset.
  
• Secondary progressive MS (SPMS) – SPMS often follows RRMS, attacks are less and less frequent, but the symptoms are more severe and permanent. SPMS is also characterised by constant deterioration of function over time. Treatment of RRMS can delay or sometimes prevent progression to SPMS.
  
• Primary progressive MS (PPMS) – PPMS is a less common type of MS, it is characterised by gradual worsening of symptoms and decline in function, attacks are relatively rare.
  
• Progressive/relapsing MS (PRMS) – PRMS is a rare type of MS, which accounts for about 5% of MS cases. The disease can appear similar to PPMS, whereby a steady decline in function is observed, but PRMS is also accompanied by occasional attacks, similar to SPMS.

Categorising MS does not have a one-size-fits-all approach, each person experiencing MS may have different onset, symptoms, and MS attack frequency. 

What are the symptoms of multiple sclerosis?

Symptoms of MS vary among individuals. The common symptoms of MS include:

• Numbness and tingling sensation
• Electric shock sensation, especially if it is triggered by certain movements
• Lack of coordination
• Vertigo or imbalance
• Trouble with walking, inability to walk
• Weakness 
• Fatigue 
• Vision loss (can be of one eye or both eyes), double vision, blurred vision, or pain with eye movements
• Trouble swallowing 
• Trouble speaking
• Cognitive impairment, such as confusion, memory loss, or difficulty concentrating
• Trouble with bowel control, incontinence, or sexual function
• Mood disorders such as depression and anxiety

Many of these symptoms may appear suddenly and can come and go, especially in the early stages known as relapsing-remitting MS. If you or a loved one experiences any of the following, do consult a neurologist for early evaluation and proper treatment.  

What causes multiple sclerosis?

MS is thought to be caused by a combination of immune reactivity, genetics, and environmental factors [1]. 

• Viral infection — Researchers postulated that the body’s immune system becomes reactive due to an initial stimulation by an unknown antigen, which activates T-helper cells (Th1 and Th17), this causes the Th1 and Th17 cells to adhere to the central nervous system (CNS) endothelial cells, leading to blood-brain-barrier (BBB) penetration, subsequently causing an immune attack due to cross-reactivity [1, 3], where the immune cells mistaken the healthy CNS cells as antigens from harmful pathogens, such as viruses.

• Environmental triggers — Scientists also believe that environmental factors such as vitamin D deficiency and viral infections play a role in the stimulation and progression of MS.

• Genetics — Genetics also play a role in the likelihood of developing MS, having a family member with a history of MS increases the risk of MS. A common gene implicated in MS is the human leukocyte antigen (HLA) DRB1*1501 [4].

• Smoking — Smoking can increase your risk of MS and accelerate the disease’s progression.

Who is at risk of multiple sclerosis?

The pathophysiology of MS involves interactions between many factors, having some of these factors inherently increase the risk of developing MS.

• Age – MS can develop at any age, but most cases have an onset between ages 20 to 40 years old.
  
• Sex – Women are more likely to develop MS compared to men, as is common with most autoimmune conditions.
  
• Genetics – Familial history of MS can increase the risk of developing MS up to% 2 to 4% compared to 0.1% in the general population [1].
  
• Infections – Viral or bacterial infections may promote development of MS in genetically susceptible individuals [3].
  
• Vitamin D deficiency – Vitamin D deficiency has been implicated in MS. Race/ethnicity and geographical prevalence of MS is also linked to vitamin D deficiency. Studies reported that countries with lower exposure to sunlight have a higher prevalence of MS [1, 3].

How is multiple sclerosis diagnosed?

There are no specific tests to diagnose MS, doctors often use a combination of clinical symptoms, medical history, and laboratory tests to diagnose MS. Common diagnostic tests and examinations for MS are as follows:

• Clinical presentation – Clinical symptoms and medical history of MS attacks are important for your doctor to determine your cause of symptoms.
  
• Neurological examinations – Sometimes, your doctor may also perform neurological examinations to assess your nerve and cognitive functions.
  
• Magnetic resonance imaging (MRI) scan – MRI scans are useful in looking for MS lesions on the brain.
  
• Lumbar puncture – Lumbar puncture is a procedure used to obtain samples of your cerebrospinal fluid (CSF). The CSF samples will then be sent for more laboratory diagnostics to look for inflammatory cells, antibodies, as well as to rule out other conditions that may resemble MS, such as infections.
  
• Blood tests – Similar to a lumbar puncture, blood tests use blood samples taken from you to look for MS markers as well as to rule out other conditions such as infections or metabolic disorders that may have similar symptoms to MS.
  
• Evoked potential test – Evoked potential test involves using electrodes placed on the skin to evoke a response from your nervous system. The test measures how quickly your nerves respond to the stimuli, demonstrating slowed or impaired conductivity which may indicate MS.

How is multiple sclerosis treated?

Treatment of MS can be done in several approaches [2].

Managing MS attacks

MS attacks typically occur as acute cases of relapse, common treatments used in managing these attacks include:

• Corticosteroids – Corticosteroids are used to reduce inflammation associated with MS attacks, commonly given as an oral dose with prednisone or an intravenous dose with methylprednisolone for a period of 3 to 7 days. Common side effects with corticosteroid include gastrointestinal issues, insomnia, hypertension, osteoporosis, high blood sugar and mood disturbances [2].
  
• Plasma exchange – Severe MS attacks that do not respond with corticosteroids are typically treated with plasma exchange, or plasmapheresis. The procedure involves taking blood from the patient, separating the blood cells from the plasma, followed by mixing with a solution of albumin, and then putting it back in the body. The procedure is done between 5 to 7 times for 14 days [2].

Disease-modifying treatments

Disease-modifying therapies (DMTs) target to halt or slow the progression of MS, as well as to reduce the frequency of MS attacks. Various DMT medications are available for MS, the common ones include [1 - 3]:

• Interferon-beta medications – Interferon-beta medications are commonly used in the treatment of RRMS. The drugs work by a number of mechanisms, including regulating anti-inflammatory cytokines expressions, modulating Th1 and Th17 function, reducing the adhesion and infiltration of T-cells on the CNS endothelium and BBB, and reducing antigen presentation of B-cells [5]. Interferon-beta medications are typically given as injections with common side effects such as injection-site reactions, flu-like symptoms, and elevated levels of liver enzymes [6].
  
• Glatiramer acetate – Glatiramer acetate acts as a mimic to myelin basic proteins, hence acting as a decoy to the body’s immune system to bind to the drug molecules instead on the myelin proteins [7]. Glatiramer acetate also reduces immune activation and has neuroprotective and neuroregenerative properties. However, the drug may not be effective in progressive forms of MS [1]. Glatiramer acetate is also given as an injection.
  
• Natalizumab – Natalizumab is a monoclonal antibody against α4β1 integrin on the surface of leukocytes, this blocks adhesion of the leukocytes to the vascular endothelial cells, preventing them from migrating out of the blood vessels and onto the CNS tissues [8]. Natalizumab is given as intravenous infusions with common side effects such as hives, mild headaches, and joint pain [6].
  
• Mitoxantrone – Mitoxantrone is a chemotherapeutic drug used for cancer, but can also be used for treatment of MS, due to their suppressive and inhibitory effects in B-cell and T-cell function, antibody production, and macrophage-mediated myelin degradation [9]. Mitoxantrone is also given as an infusion.
  
• Fingolimod – Fingolimod is an immunomodulating drug, which acts by inhibiting T-cell migration. The medication is taken orally, common side effects include headache, diarrhoea, back pain, elevated liver enzymes, oedema, and bradyarrhythmia [6].
  
• Dimethyl fumarate – Dimethyl fumarate exerts anti-inflammatory and immunomodulatory effects, reducing inflammatory response and CNS infiltration by immune cells in patients with relapsing MS. Dimethyl fumarate is also taken as an oral medication, with common side effects such as flushing, abdominal pain, diarrhoea, nausea, rashes, and lymphopenia [6].
  
• Monoclonal antibodies – Monoclonal antibodies used in the treatment of MS include ofatumumab, ocrelizumab, and alemtuzumab target the antigens on B-cells and T-cells such as CD20 and CD52 [3].

Selection of DMTs depends on various factors, including disease progression, symptoms, patient’s age and condition, treatment history, pregnancy plans, as well as costs. A comprehensive and thorough diagnosis is necessary for your doctor to decide on the most suitable MS treatment for your needs.

Symptomatic treatments

Symptomatic relief can help patients improve their life with MS.

• Therapy – Physical therapy can aid with regaining muscle strength mobility in patients who have trouble with walking or coordination. If necessary, a walking aid may also be used for getting around.
  
• Therapy and medications for mood disorders – Mood disorders associated with MS, such as depression and anxiety can be treated with psychotherapy or with the use of medications such as antidepressants.
  
• Medications for incontinence/bowel issues – MS can also lead to problems with incontinence and bowel issues, medications may be prescribed by your doctor to manage these problems.

Summary

MS is a chronic autoimmune disease that affects the CNS. Treatment of MS should ideally be given at the early stages of the disease to delay or prevent disease progression and reduce MS attacks. For this reason, early detection and diagnosis is important for effective management of MS. 

If you have any questions or concerns relating to MS or MS management, reach out to us to book a consultation session with our doctors.

Frequently Asked Questions

Can I live normally with multiple sclerosis?

MS can be different for each person with the disease. As MS is a chronic disease, it may progress and lead to disability. If caught early, you may be able to lead a normal life with proper disease management and treatment, thereby preventing progression to disability. 

How long can I live with multiple sclerosis?

Previously, it was thought that MS can shorten a person’s life expectancy by 7 to 10 years. However, recent advances in MS treatments have improved the overall life expectancy for someone with MS. It is also important to note that the disease varies with each person and life quality and expectancy may vary as well.

Can multiple sclerosis be stopped?

Early detection and treatment of relapsing MS can be treated with DMTs to slow down the progression of the disease.

Is MS fatal?

Typically, MS is not fatal and those with MS experience a near-normal lifespan. However, in rare, complex cases, MS may reduce life expectancy. 

What can trigger an MS relapse?

An MS flare-up happens when new symptoms occur or existing symptoms worsen for more than 24 hours. Common triggers include:

• Infections
• Physical or emotional stress
• Lack of sleep 
• Heat or overheating 
• Skipping medications 
• Hormonal changes 
• Smoking

References

1. Tafti D, Ehsan M, Xixis KL. Multiple Sclerosis. 2024 Mar 20. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan–. PMID: 29763024.
2. Haki M, Al-Biati HA, Al-Tameemi ZS, Ali IS, Al-Hussaniy HA. Review of multiple sclerosis: Epidemiology, etiology, pathophysiology, and treatment. Medicine (Baltimore). 2024 Feb 23;103(8):e37297. doi: 10.1097/MD.0000000000037297. PMID: 38394496; PMCID: PMC10883637.
3. Dighriri IM, Aldalbahi AA, Albeladi F, Tahiri AA, Kinani EM, Almohsen RA, Alamoudi NH, Alanazi AA, Alkhamshi SJ, Althomali NA, Alrubaiei SN, Altowairqi FK. An Overview of the History, Pathophysiology, and Pharmacological Interventions of Multiple Sclerosis. Cureus. 2023 Jan 2;15(1):e33242. doi: 10.7759/cureus.33242. PMID: 36733554; PMCID: PMC9888604.
4. Alcina A, Abad-Grau Mdel M, Fedetz M, Izquierdo G, Lucas M, Fernández O, Ndagire D, Catalá-Rabasa A, Ruiz A, Gayán J, Delgado C, Arnal C, Matesanz F. Multiple sclerosis risk variant HLA-DRB1*1501 associates with high expression of DRB1 gene in different human populations. PLoS One. 2012;7(1):e29819. doi: 10.1371/journal.pone.0029819. Epub 2012 Jan 13. PMID: 22253788; PMCID: PMC3258250.
5. Filipi M, Jack S. Interferons in the Treatment of Multiple Sclerosis: A Clinical Efficacy, Safety, and Tolerability Update. Int J MS Care. 2020 Jul-Aug;22(4):165-172. doi: 10.7224/1537-2073.2018-063. Epub 2019 Oct 30. PMID: 32863784; PMCID: PMC7446632.
6. Robertson D, Moreo N. Disease-Modifying Therapies in Multiple Sclerosis: Overview and Treatment Considerations. Fed Pract. 2016 Jun;33(6):28-34. PMID: 30766181; PMCID: PMC6366576.
7. Babaesfahani A, Patel P, Bajaj T. Glatiramer. [Updated 2024 Feb 28]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK541007/
8. Selewski DT, Shah GV, Segal BM, Rajdev PA, Mukherji SK. Natalizumab (Tysabri). AJNR Am J Neuroradiol. 2010 Oct;31(9):1588-90. doi: 10.3174/ajnr.A2226. Epub 2010 Aug 5. PMID: 20688889; PMCID: PMC7964985.
9. Fox EJ. Mechanism of action of mitoxantrone. Neurology. 2004 Dec 28;63(12 Suppl 6):S15-8. doi: 10.1212/wnl.63.12_suppl_6.s15. PMID: 15623664.