MS Update

Sep 28, 2017

  1. Trevor Shewfelt, Pharmacist at the Dauphin Clinic Pharmacy

I was thinking of a one legged Manitoban athlete this week. Not the world famous Terry Fox, eventhough I visited his memorial east of Thunder Bay this summer, and the cancer fund raising run in his name has just past. I didn't catch this guy's name. He was a little older, had grey hair but otherwise looked trim and fit. Then he jumped on a bike at the MS Bike tour and took off with the elite riders in the front. I'm used to nearly everyone, including my kids, people on tandem bikes, and nearly everyone else except the 80 year olds passing me in the MS Bike tour from Dauphin to Clear Lake. But the cyclist with one leg amazed me. I'm honestly not sure how you balance on a bike with one leg, let alone cycle up hill, but he did it with ease. It is amazing what someone can accomplish if they put their mind to it.

During one of the organizing meetings for the MS Bike Tour, I looked up and say a poster. It said, "Canada leads the world in Maple Syrup, Hockey and Multiple Sclerosis." Canada has one of the highest rates of MS in the world. The Manitoba and Saskatchewan area have one of the highest rates of MS in Canada. We believe it is our own immune system that attacks the myelin sheath around the nerve fibers in MS. We also believe that if we suppress the immune system that will reduce MS symptoms. Before the first MS Riding Mountain Challenge, back in 1993, we didn't have any medications available to suppress the immune system. After over 20 years of Bike Tours, we have 14 powerful immune suppressing drugs to treat MS. However, many of these immune suppressors are injectable and very expensive. Wouldn't it be nice if there were cheaper, simpler, oral options? Researchers in Calgary might have that simple option for us. And they just published their results in the June 1, 2017 New England Journal of Medicine.

Let's back up. What is MS or multiple sclerosis? It is an unpredictable and often debilitating disease of the brain and spinal cord. Some of the long nerves in the brain and spinal cord have a covering called myelin. Remember when all phones were connected to the wall with a cord? Myelin works a like the plastic covering around the telephone cord. Without the insulating plastic cover, some of the signal that goes down the telephone wire would leak out. The voice on the phone would sound delayed, weakened, garbled or possibly not there at all. In MS, the immune system mistakenly attacks the insulating myelin sheath around some of the nerve fibers. That makes the signals from the brain to the body or body back to the brain get weaker, delayed, garbled or go missing altogether.

Multiple Sclerosis is the most common neurological disorder in young adults. Every day, three more people in Canada are diagnosed with MS. It is estimated that more than 100,000 Canadians have Multiple Sclerosis. Around 3500 people in Manitoba have MS. Women are more than three times as likely to develop MS as men. MS can cause loss of balance, impaired speech, extreme fatigue, double vision and paralysis.

Since MS affects some myelin covers some of the time, this leads to one of the most fascinating and frustrating facets of the disease. The symptoms of MS can change and are unpredictable. The most common form of MS, relapsing and remitting MS, has well defined attacks followed by complete or partial recovery. It can go away and come back. And it can affect vision, hearing, memory, balance and mobility. And this is not just that the disease affects different people in different ways! The same person can have different symptoms each attack. You can imagine how frustrating it would be to both worker and employer if a worker came to work one week in a wheel chair and then the next month she could walk. Then six months later she could still walk, but says she can't read her computer screen without magnification. And then she is fine. And then a year later she calls in sick for 3 weeks because she is too fatigued to leave the house. Unfortunately, since people with MS often don't look sick and they have symptoms that come and go, some confused employers treat employees with MS unfairly.

A Canadian clinical trial led by researchers at the University of Calgary's Hotchkiss Brain institute looked at an antibiotic commonly used to treat acne called minocycline. They found that minocycline can slow the progression of relapsing-remitting MS in patients who have just experienced their first symptoms. Luanne Metz et al. enrolled 142 patients across 12 Canadian MS Clinics including the one in Winnipeg. These participants had experienced their first MS symptoms during the previous 6 months. Half the participants got minocycline 100mg twice a day and half got placebo. The research team wanted to know how many of these people with only one attack of MS, which is sometimes called clinically isolated syndrome, went on to develop full blown MS.

At 6 months 61% of the placebo group had developed full blown MS, while only 33.4% of the minocycline group had. By 24 months pretty much as many people in the minocycline group had full blown MS as in the placebo group. Now that might sound disappointing, but it really is in line with what our current MS immune suppressing drugs can do. They delay the onset of more severe symptoms. Minocycline seems to delay the onset of more severe symptoms by up to 2 years. It is inexpensive, a pill not an injection and something neurologists can start using today! Since minocycline is already approved for use in Canada, the MS doctors don't have to wait for any other Health Canada approval.

Another type of MS is called primary progressive MS. In primary progressive MS, the symptoms start and just get worse over time. There is no "getting better" phase. A couple years ago, we had no treatments for primary progressive MS. But thanks to researchers and fund raising, a study called Oratorio had 732 participants with primary progressive MS. One third of the participants got a placebo and two thirds got ocrelizumab. Compared to placebo the ocrelizumab reduced the risk participants would get worse at a timed 25 foot walk, reduced having their MRI measured lesion volume get worse and reduced the chance of having their brain volume go down as measured on MRI. How does ocrelizumab work? Ocrelizumab is an antibody to the protein CD20. CD20 is a protein on the immune cell called B cells. B cells are believed to be involved in the abnormal immune response in MS. Ocrelizumab binds to CD20, found on the surface of B cells, and causes cell death. The more ocrelizumab injected, the more the B cells are depleted and less damage to the myelin sheath around nerve cells. Ocrelizumab has been approved by the FDA in the US and we hope for Health Canada approval soon.

Looking down the road, Dr. James Marriott and colleagues in Winnipeg and Ottawa are looking to see if stem cell treatments can help treat MS with the MESCAMS study. There are many years of hard work ahead, but the future of MS treatment and possibly a cure looks bright.

The MS Bike ride, the Terry Fox run and the Ronald McDonald House Red Shoe Crew Walk were all held in September. I know they are all still accepting donations for Multiple Sclerosis, Cancer and Ronald McDonald House Children's Charities. I'm obviously biased to the MS Ride because I have so many good memories of it. The rain, the heat, the hail, the tail winds, the head winds and the super friendly volunteers have been wonderful over the years. I remember years ago helping a young Jake Klassen up the hills. In the last 4 years I've helped my own kids. The MS Bike ride from Dauphin to Clear Lake and back is a 20 plus year tradition that started with a meeting of a few people at Boston Pizza in the mid 90's. Just like riding up a hill with one leg, running across the country on one leg, or helping sick kids and their families, it is amazing what can be accomplished if you put your mind to it.

As always if you have any questions or concerns about these or other products, ask your pharmacist.

The information in this article is intended as a helpful guide only. It is not intended to be used as a substitute for professional advice. If you have any questions about your medications and what is right for you see your doctor, pharmacist or other health care professional.

We now have most of the articles published in the Parkland Shopper on our Website www.dcp.ca

MS Society of Canada www.mssociety.ca

Minocycline and MS - https://mssociety.ca/resources/news/article/common-acne-medication-offers-new-treatment-for-multiple-sclerosis

NEJM article on Minocycline and MS Trial - http://www.nejm.org/doi/full/10.1056/NEJMoa1608889?query=featured_home&

Ocrelizumab and ORATORIO Study - https://mssociety.ca/research-news/treatments-in-development/ocrelizumab2

 


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