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The purpose of this material is to make it clear to a person without medical education how vast and complex is the problem multiple sclerosis. Very often patients undergoing MRI the brain are one on one with their problem.
After all, it happens that a specialist describes an MRI and finds suspicion of a focus of demyelination. After this patient should see a doctor at the center of multiple sclerosis. Alas, such centers located only in large cities, and the patient, having no idea about what demyelination is and why it is dangerous, just nothing undertakes. Many years later, if a person really there is multiple sclerosis, it becomes a deep invalid just because time is lost.
The second important reason for this material to appear is the data. Ministry of Health of the Russian Federation, which indicate that over the past 5 years, the number of patients with multiple sclerosis increased by 20,000 people, and last year there were only over 80,000 patients have been registered. At the same time, the highest incidence recorded in St. Petersburg, more than one case per 1000 population. The fact that that annually in Russia grows 7% of patients with this diagnosis.
To a large extent, the situation is complicated by the fact that a quarter of drug tenders in Russia this year were disrupted ( https://www.bfm.ru/news/422701). Patients did not receive insulin, 75% bidding for rabies vaccine did not take place, and in the same St. Petersburg, in which the incidence is highest in the country, people have not been able to get medicine for scattered for a whole year sclerosis. That is, the doctor prescribes the drug, and his state cannot provide, although required. The consequences of untimely treatment, and just the lack of drugs can be catastrophic: disability and exacerbation rate progressing.
- What is MS?
- Nerves are wires!
- How is MS manifested?
- Attention! Dangerous symptoms!
- Caution: overheating!
- How is MS diagnosed?
- Prognosis and treatment goals
- Treatment of MS, or multiple sclerosis
- How to treat exacerbations?
- Methylprednisolone (Metipred, Ivepred, Solu-medrol)
- Cyclophosphamide (Endoxan, Cyclophosphamide)
- Other treatments for exacerbations
- PITRS two lines
- Means of the first line PITRS
- Low-dose interferon beta-1a for i / m administration (Avonex)
- High-dose interferon beta-1a for sc administration (Genfaxon, Rebif)
- Interferon Beta-1b (Ronbetal, Infibeta)
- PEG-interferon beta-1a (Plegridi)
- Glatiramer acetate (Copaxone, Axoglathiran, Timexon)
- Teriflunomide – tablets (Abaggio)
- Dimethyl fumarate – tablets (Tecfidera)
- The second line of PITRS
- Natalizumab (Tisabri)
- Fingolimod (Gilenia)
- Alemtuzumab (Lemtrada)
- Okrelizumab (Okrevus)
- Organizational features of the appointment of PITRS
- Conventional medicine
What is MS?
First of all, multiple sclerosis is not forgetfulness at all, then there is absent-mindedness, and not the vascular sclerosis that is spoken of in everyday life, lamenting for memory. It is chronic, and yet incurable. a disease that affects the myelin sheath of nerves and structures CNS The process that leads to the symptoms of multiple sclerosis is this is demyelination, that is, the gradual breakdown of the nerve membranes. TO what does this lead to?
Everyone knows that nerves, as well as bundles of nerve fibers in various types of spinal cord and brain Sensitivity: temperature, pain, tactile. Nerves carry information about the musculoskeletal feeling, through which we with with closed eyes we understand the position of our arms and legs in space. Cranial nerves bring to the brain all kinds specific sensitivity, vision, hearing, smell, feeling equilibrium. The command signals are coming back from the brain. This is, above all, muscle contraction.
Nerves are wires!
Simply put, nerves are nothing but electric wires, only the conductor is not a metal, but an electrochemical process in the membranes of nerve cells. Maximum speed pulse – up to 120 m per second, this is enough to ensure the fastest reactions. But what happens if the insulation of the wire damaged? Imagine a thick cable that feeds a whole the house has a poor-quality outer or inner braid. Then wires begin to sparkle and various short short circuits. Therefore, if in the switchboard, somewhere in the basement if the cable is damaged, these consequences can manifest very far from the place of damage. So, for example, the light may go out selectively in several apartments, which are supplied with electricity from the affected area. As a result, in one apartment it will become dark in another – the washing machine will turn off, and in the third it will stop work computer. Approximately the same situation occurs with multiple sclerosis. With it, all kinds of sensitivity are violated, and later paralysis develops, which can lead to complete stillness. It is proven that multiple sclerosis is autoimmune disease. The body forms harmful antibodies, which induce the process of inflammation, and themselves destroy the myelin the sheath of their own nerve structures, considering it to be foreign.
Multiple sclerosis is known to be the most common cause. disability in young people associated with nervous diseases. It’s important that with multiple sclerosis, intelligence never suffers, and people are fully aware of the progression of their illness, remaining in sound mind and clear memory. There are currently over 700 in Europe thousand people live with this diagnosis, and in total there are more than 2.5 million patients with multiple sclerosis. How does it manifest is this disease and how is it going?
How is MS manifested?
This disease can occur in different ways. In some cases, the patient periodically worsens, then there comes an improvement, and then again deterioration. In this case talk about remitting course. Sometimes after each exacerbation the patient returns to his previous state, and sometimes the improvement is all equally does not reach the best results of the previous one, and each subsequent exacerbation leads to the development of new symptoms. Sometimes multiple sclerosis can occur without any remissions and improvements, that is, with continuous and constant deterioration. This is the most unfavorable situation. In this case, the course of the disease in any case – a process stretched over many years, multiple sclerosis is lifelong disease.
But, unfortunately, even having an accurate and definitely reliable the diagnosis, neither the patient nor the doctor can predict what will arise new symptoms. They can be extremely diverse, and depend from where exactly the myelin sheath is destroyed in the structures central nervous system. Here are the most common first symptoms of multiple sclerosis, according to which the patient usually Turns to the therapist, and then to the neurologist. Usually after the story about these symptoms as a result of neurologists and prescribe an MRI of the head brain.
Attention! Dangerous symptoms!
If you or your loved ones are young or middle aged If the following signs appear, you must immediately contact neurologist. They may indicate a decay process. myelin:
- paresthesia, that is, a feeling of numbness and tingling in limbs and body, sensation of “crawling creeps”;
- muscle weakness on one side of the body, left or right, or periodic weakness in the limbs. It can grow;
- decreased vision, veil before the eyes, decreased clarity (sometimes it can be in one eye), up to the transitory blindness, occasional double vision;
- sometimes the debut of multiple sclerosis is associated with the presence of pain in the eye and decreased vision, the so-called retrobulbar neuritis;
- dizziness, tremor;
- spasticity and increased muscle tone;
- pelvic disorders.
More than half of all patients with multiple sclerosis have urination disorders. Most often these are imperative urges, when you need to immediately, right now, urgently empty the urinary bubble. The second symptom is a reflex urinary retention when you need to use the toilet, but you can’t immediately empty the bubble, you must some time for urine to go
Patients with these symptoms should began to be very cautious about heat and overheating of the body. If they don’t have multiple sclerosis, then such a precaution doesn’t hurt, but if it’s still diffuse sclerosis will be confirmed, then this tactic will avoid aggravation, progression, and maybe, but several years will delay the appearance of signs of disability.
It’s about that myelin is destroyed at an increased rate at high temperature. In such patients, exacerbation, amplification, and the appearance of a new all of the above symptoms, arises after:
- prolonged exposure to the sun, including after lying on the beach;
- taking a hot bath and shower;
- stay in the bath and sauna.
In some cases, deterioration may occur even after plates of too hot soup or mugs of very hot tea. It’s especially dangerous for such patients to catch a cold, since fever how an increase in body temperature also worsens the course of the disease. Therefore, patients who are suspected of demyelinating process, it is desirable to be in public as little as possible places in the midst of an epidemic, wear a disposable mask, avoid hypothermia, and even refuse vaccinations temporarily, by medical indications. After all, after vaccinations quite often an adverse reaction such as a flu-like syndrome occurs.
How is MS diagnosed?
In order to make or refute the diagnosis of scattered sclerosis, the following diagnostic steps are mandatory:
- if the neurologist finds specific abnormalities in neurological status, then he directs the patient to an MRI of the head brain. Such deviations may be external internal ophthalmoplegia, nystagmus, absence of abdominal reflexes, pyramidal symptoms indicating signs of central paralysis and others symptoms that the patient himself cannot determine;
- according to MRI of the brain with contrast, the tomograph does not less than 1.5 T, the patient in the classic case find foci demyelination, that is, the breakdown of the same myelin sheath.
- The white matter of the brain is known to be thick and compact bundles of nerve fibers, therefore a favorite the location of the demyelinating foci is an area surrounding lateral ventricles, or periventricular location. If such changes are detected, then it will be necessary to do MRI, so that doctors can make sure that these foci are changing their position, quantity and size. If compliance is established complaints, the history of the development of the disease, the clinical picture, and there are foci, then the diagnosis can be considered established;
- if there are no such foci, or they are not very characteristic of multiple sclerosis, then you have to appoint a spinal puncture to examine specific antibodies of the spinal fluids, the so-called oligoclonal immunoglobulins. By modern criteria of 2017, you can look for them, earlier, this will make it possible to diagnose multiple sclerosis more accurately and more reliable.
The most important thing in diagnosis is to correctly determine the type of flow diseases, because the list of drugs depends on it drugs that are used selectively: what heals with remitting form, not shown in primary progressive, eg.
Prognosis and treatment goals
Unfortunately, despite the fact that multiple sclerosis suffers several million people in more than 150 years of history no case known independent and complete recovery. Multiple sclerosis only works in one direction, the patient’s condition is gradual worsens, and disability symptoms increase. But even in the most in severe cases, the patient dies not from multiple sclerosis, but from complications associated with deep disability and immobility. This is hypostatic pneumonia, bedsores, paresis intestines, urinary tract infection and other conditions, t Familiar to everyone who cares for seriously ill patients.
However, do not despair. If the diagnosis is made early, and therapy started in a timely manner and correctly, then you can not only do exacerbations more rare and less pronounced, but also delay the onset of disability. In some cases, delaying clinically severe disability symptoms can be made at 15, 20 years old, and even longer. Therefore, the main goal of treatment will be to slow down course of the disease.
Treatment of MS, or multiple sclerosis
|Nomination||a place||Name of product||price|
|Medications||1||Methylprednisolone (Metipred, Ivepred, Solu-medrol)||151 rub|
|2||Cyclophosphamide (Endoxan, Cyclophosphamide)||141 rub|
|3||Other treatments for exacerbations||–|
|Means of the first line PITRS||1||Low-dose interferon beta-1a for i / m administration (Avonex)||47 000 rub.|
|2||High-dose interferon beta-1a for sc administration (Genfaxon, Rebif)||3 200 rub.|
|3||Interferon Beta-1b (Ronbetal, Infibeta)||1 246 rub.|
|4||PEG-interferon beta-1a (Plegridi)||RUB 28,995|
|5||Glatiramer acetate (Copaxone, Axoglathiran, Timexon)||8 005 rub.|
|6||Teriflunomide – tablets (Abaggio)||17 490 rub.|
|7||Dimethyl fumarate – tablets (Tecfidera)||59 000 rub.|
|The second line of PITRS||1||Mitoxantrone||8 700 rub.|
|2||Natalizumab (Tisabri)||53 000 rub.|
|3||Fingolimod (Gilenia)||97 000 rub.|
|4||Alemtuzumab (Lemtrada)||615 000 rub.|
|5||Okrelizumab (Okrevus)||220 000 rub.|
In general, the treatment of multiple sclerosis consists of two large sections: this is a planned therapy, which is shown to the patient based on forms of the disease over time (PITRS preparations apply for at least several years), and this a kind of “emergency therapy”, or relief of exacerbations illnesses.
In the treatment of multiple sclerosis, the usual medicines that are used in neurology. But these symptomatic drugs do not alter the course of the disease, and therefore, they do not affect the progression of disability. In Russia patients can also receive drugs such as cerebrolysin, Mexidol, Cortexin, Actovegin, But all these drugs do not have proven effectiveness, and if they and only they are offered treat multiple sclerosis – such a doctor is at least quack.
Below we will consider really working medicines. Should say that the full, competent treatment of multiple sclerosis the best original imported drugs – very expensive. Therefore, in the Russian Federation there is a register of patients multiple sclerosis, and if there is a confirmed diagnosis relies on free treatment.
Naturally, in the light of modern trends, patients in pharmacies offer first cheap domestic counterparts. Do they have agents for treating MS. But as we can see, even these free guaranteed domestic drugs, patients sometimes do not receive.
How to treat exacerbations?
First, imagine that the patient is diagnosed with diffuse sclerosis for the first time, and just against the background of the most vivid picture the deployment of new neurological symptoms, that is, during exacerbations. What should be done with exacerbation? It needs to be stopped. AND because, as mentioned above, multiple sclerosis is autoimmune disease associated with the development of specific inflammation leading to the destruction of myelin, it is necessary suppress the strongest anti-inflammatory drugs, and also drugs from the group of cytostatics. In all cases exacerbations need to hospitalize the patient in profile neurological department, and only to those “tested” patients, exacerbations which are well known to the doctor, and which are good and repeatedly stopped, you can be treated in daylight a hospital.
Methylprednisolone (Metipred, Ivepred, Solu-medrol)
Exacerbations of multiple sclerosis are suppressed by administration high doses of corticosteroid hormones. This is the so-called pulse therapy. Usually 1 gram (1000 mg) is used for it. methylprednisolone daily intravenously in saline for 3 days. Thus, in 3 days, 3000 mg is administered to the patient. methylprednisolone. This is one of the common schemes, but there are and other methods of conducting pulse therapy.
Hospitalization is necessary for the use of methylprednisolone, because a large amount of hormones is injected quickly. The patient anxiety may develop, appetite may change. There is nausea insomnia, cardiac arrhythmia, increased blood sugar, or even psychosis. High doses of corticosteroid hormones are dangerous for the patient with exacerbation of erosive and ulcerative gastritis or stomach ulcers. therefore to prevent the appearance of ulcers, it is mandatory along with pulse therapy either H2-blockers of histamine receptors or blockers are prescribed proton pump, e.g. omeprazole.
High doses of hormones contribute to the loss of potassium and calcium, this everything must be taken into account when conducting pulse therapy. Methylprednisolone not only relieves exacerbation, but also can slow the progression of special forms of multiple sclerosis, for example, a secondary progressive form. In this case, the pulse therapy can be carried out every 2 months in a planned manner, also in within 3 days, but the dose will be half that 500 mg.
Of the modern preparations of methylprednisolone, the largest Pfizer company Solu-medrol is popular. He infrequently happens in pharmacies, and an injection bottle of 250 mg will cost 350 rub. The Metipred drug will cost about 380 rubles for the same dosage manufactured by Orion, Finland. Thus, for one day of pulse therapy, four such bottles are needed, and on the whole course – 12. Accordingly, the cost of Metipred per course pulse therapy will be 4560 rubles. for 3 days. Sure, the patient can provide domestic, cheaper analogues free, but here you need to think not only about the price, but also about quality of treatment.
Cyclophosphamide (Endoxan, Cyclophosphamide)
If the patient has an adverse course of multiple sclerosis, in which exacerbations are too frequent, and new ones develop rapidly neurological symptoms, including motor disorders, then it is desirable to combine pulse therapy with the introduction of cytostatics, for example cyclophosphamide, or use other separate or combined use of these drugs.
Cytostatics are usually given in high doses with malignant tumors, but they also stop and inflammatory autoimmune process. Therapy with cytostatics for exacerbations multiple sclerosis is prescribed to patients in significantly smaller dosages than in oncology, and shorter courses, therefore side effects characteristic of them are observed quite rarely. Cyclophosphamide is usually given in doses of 500 mg for three days, or 100 mg. daily.
Keep in mind that the dosage is indicated in milligrams per one square meter of body area, and for the right purpose doses special calculation formulas are needed. Endoxan Cost, which is produced by the German company Baxter-oncology, is from 200 rub. per pack of powder for intravenous solution administration in a dosage of 200 mg. So, for an adult male with a height of 190 cm, having a weight of 100 kg, the surface area of the body will be according to one of the formulas 2.28 square meters. Respectively, the daily dose required to relieve exacerbation will be make up just one package.
Although side effects are quite rare, it is necessary always bear in mind that cytostatics worsen the composition of the blood, cause nausea, vomiting and anorexia, increase liver enzymes ALT and AST, sometimes a cardiotoxic effect occurs, amplified fibrous process in the lungs, and from the reproductive system the synthesis of eggs and sperm cells is disturbed.
Other treatments for exacerbations
It must be said that not all exacerbations of diffuse sclerosis without fail require the appointment of such a “severe artillery “, like pulse therapy or cytostatics. If it is an exacerbation is short-term and light in nature, then they can do and conventional drugs without pulse therapy.
Currently, plasmapheresis sessions are very helpful when do without medication at all. By the way, if an exacerbation of diffuse sclerosis occurred in a pregnant or lactating woman, then can be stopped only by plasmapheresis sessions., since hormones, especially cytostatics are categorically contraindicated.
In this case, the patient exchanges within 15 days in total up to one and a half volumes of blood plasma for each session, (from 3 to 5 sessions in 2 weeks). Plasmapheresis is also indicated in those patients which have no effect with the introduction of corticosteroid hormones. Properly conducted regular plasmapheresis sessions support remissions, and are able to significantly reduce manifestations disability. Improvement in plasmapheresis usually occurs on the second – the fourth day of the sessions.
PITRS two lines
This is a Russian-language abbreviation. It means “drugs, altering the course of multiple sclerosis, “PITRS. Hormones and cytostatics, which are used as “heavy artillery” in treatment of exacerbations, the exacerbation is treated, and their symptoms are stopped. But here on the course of multiple sclerosis means for relief of exacerbations practically do not affect. Accordingly, not the timing of the onset of disability is also changing. Since scattered sclerosis most often moves toward disability by steps, or jerks associated with the occurrence of exacerbations were found medicines that prevent these very exacerbations.
Because they put off the onset of disability for years to come with proper treatment, they were called drugs that change course of multiple sclerosis, or PITRS. And these drugs come in two lines, the first and second lines. Second line funds are a kind of reserve, and they are prescribed to those patients who have the appointment of first-line funds there is no expected effect.
Means of the first line PITRS
After the exacerbation is stopped, it is necessary to appoint drug from this group. If the patient was diagnosed with MS outside the stage of exacerbation, then he immediately, necessary, after complete confirm the diagnosis and in the absence of contraindications appoint one of the drugs PITRS. Of course, “immediately” can only be paid: while the patient goes through all the stages of the Russian bureaucratic machine health, it may take more than one month, and in some cases you can even go without medication.
Low-dose interferon beta-1a for i / m administration (Avonex)
Avonex is an import preparation of the Hungarian company Gideon Richter And it is indicated for intramuscular administration once a week, with this form of the disease called remitting. It must be administered once a month, and especially good for the mild course of multiple sclerosis, including children. Avonex reliably pushes back the rate of progression diseases.
Side effects include fever, the so-called flu-like syndrome, seals and inflammatory changes in injection site, depression and even seizures. But basically it is well tolerated.
At the beginning of treatment, the dose of Avonex is 0.25 ml at 1 week, and with the fourth week, the drug is administered intramuscularly once a week. One syringe bottle for a single injection costs 30,000 rubles. retail, accordingly, the cost of a monthly treatment is 120,000 rub. Such a high price of the drug is determined by the way it production. This is human interferon, which is not taken from donors, but synthesized artificially. It is grown on cells Chinese hamster ovary. Into these cells using recombinant technology was introduced by the human interferon gene, and cells its hamster is produced on an industrial scale. It is very difficult modern technology.
High-dose interferon beta-1a for sc administration (Genfaxon, Rebif)
These drugs are indicated in a secondary progressive form, with frequent exacerbations, as well as with remitting diffuse sclerosis. The use of Genfaxon and Rebif for a third reliably reduce the frequency of exacerbations, and also slow down the time disability. The drug is excreted subcutaneously at a dose of 44 mcg three times a a week. As in the previous case, at the beginning of treatment is required dose titration, and only at 4 weeks is the full dosage administered subcutaneously.
The drug Rebif in the amount of 3 syringes for a weekly course treatments can be purchased at pharmacies at retail, starting at a price of 6000 rub. Accordingly, the monthly treatment course will be about 25,000 rub. Genfaxon is cheaper, its monthly treatment cost – about 8000 rubles. Produces Genfaxon ZAO Biotek, Russia. Rebif – This is an Italian-made drug.
Interferon Beta-1b (Ronbetal, Infibeta)
Interferon beta-1B, which also refers to high-dose, put on the same grounds as Genfaxon and Rebif, and also subcutaneously. Only the frequency of administration is higher: Ronbetal or Infibet is delivered every other day. Similarly, the first dose titer increases, and a full dose of 1 ml begins to be administered in a month after prescribing the medicine. Unfortunately, these interferons can develop neutralizing antibodies, an average of 6 months use up to one and a half years after the start of therapy. It may lower treatment effectiveness.
Infibet is sold as a concentrate for the preparation of solution: this is a bottle complete with a solvent attached syringes, sterile wipes and disposable needles. Packaged – 15 syringes, designed for a monthly course every other day. Minimum the cost of one package and a monthly course is 11,000 rubles. Ronbetal – This is a domestic drug company Biocad, and Infibet – a product domestic company JSC Generium, subsidiaries of Pharmstandard.
PEG-interferon beta-1a (Plegridi)
This remedy is prescribed for remitting multiple sclerosis, in the case when it is inconvenient to carry out frequent injections, or the patient afraid of injections. Plegridi is administered once every 14 days, and also on a third significantly reduces the frequency of exacerbations. However, he may there are various side effects ranging from post-injection reactions and increase the level of liver enzymes, and to increase fever, headache, and nausea or vomiting. However on treatment with this type of interferon is very rare interfering therapy neutralizing antibodies in less than one percentage of cases.
125 g is administered subcutaneously, this is the full dose, and the full dose is prescribed 3 injections, that is, a month after the start of treatment. This drug since 2018 included in the list of drugs for high-cost nosology programs. Its advantage is pretty infrequently administered, this enhances patient adherence to treatment and the quality of life. According to the state register of limit selling prices of medicines in 2019, a pack of two Plegridi syringes 125 mg each (per month course of treatment) not may cost more than 20913 rubles.
Glatiramer acetate (Copaxone, Axoglathiran, Timexon)
The next drug, Copaxone, is also, unfortunately, necessary. inject subcutaneously daily at a dose of 20 mg, or at a dose twice more, that is, 40 mg, but three times a week. He suppresses autoimmune inflammation also reduces the frequency of exacerbations, and slows the progression of disability. Copaxon Enhances the Picture on MRI, that is, reduces the number of foci of demyelination and their distribution, but only after 6 or 9 months of treatment. The introduction of Copaxone begins daily, subcutaneously in a dose of 20 mg. It is prescribed for the remitting form of multiple sclerosis. Copaxon, which is produced by Israeli company Teva costs from 17 up to 28 thousand rubles for a set of 28 injections, 20 mg each. Set Designed for a month of use. Copaxone analog, Axoglathiran stands half the price.
Teriflunomide – tablets (Abaggio)
In conclusion, first-line PITRS drugs are necessary list not injections, but pills. Teriflunomide is also indicated for remitting multiple sclerosis, but it is not prescribed immediately, but only if the patient does not tolerate injections interferons. Why so? First of all, there may be more severe side effects, such as impaired liver function and pancreas, diarrhea and nausea, less often – thinning and even hair loss. In the first six months of therapy, the risk of infections is increased. On the while taking teriflunomide, it is necessary to check liver enzymes, they should not exceed 3 times the top the border of the norm. Pack of 28 tablets Abaggio, designed for a month of admission, costs 17,000 rubles at least.
Dimethyl fumarate – tablets (Tecfidera)
Dimethyl fumarate is also a tablet preparation that taken at the beginning in a dose of 120 mg twice a day, and then the dose doubles: 240 mg 2 times a day. Indications are the same: remitting multiple sclerosis. This tool is recommended to those patients who respond poorly to interferons or Copaxone. But this ideally, when the patient is not constrained in the means. Patients are not given what suits them better, but what the Ministry of Health can let go is free. The drug reduces inflammation and suppresses immunity, significantly reducing the frequency of exacerbations by 50%.
The most common adverse reactions are flushing, burning sensation and heat, sweating, diarrhea at the beginning of admission. The drug is taken under blood control, and with a decrease in lymphocytes below a certain the drug level is canceled, because the risk of such a severe complications like progressive multifocal leukoencephalopathy (PML), which can even be fatal. 14 capsules Tecfidera containing 120mg of dimethyl fumarate costs 6,000 rubles, this weekly course of treatment for a dose of 240 mg. Accordingly, monthly treatment will cost four times more: about 25,000 rubles.
The second line of PITRS
Second-line drugs are prescribed if all first-line funds were ineffective. However, if multiple sclerosis is fast, progressing inexorably, and activity of the demyelinating process is high, then these drugs the idea can be assigned to the patient immediately, when a diagnosis is made. It should immediately be said that, despite the high prices of drugs first line, they seem frivolous compared to drugs the second line of PITRS, perhaps, except for mitoxantrone. Almost all of them are monoclonal antibodies that are produced with using modern sophisticated technologies.
Opens PITRS 2 line immunosuppressant mitoxantrone. is he is surprisingly affordable, surpassing, perhaps, even some first line remedies.
It is used for aggressive and rapidly progressive forms. diseases: it significantly reduces the frequency of exacerbations and speed progression of disability symptoms by 60%.
To it as well as cyclophosphamide for the treatment of exacerbations administered according to schemes that take into account the surface area of the body, but often a dosage of 20 mg is used intravenously, once every 3 months in during the first year of therapy. Before the introduction of mitoxantrone preparation similar to pulse therapy, 1000 mg methylprednisolone intravenously. The cost of one bottle of 10 ml, just for one infusion, an average of 2000 rubles., And the cost of methylprednisolone, on average, 400 rubles. Thus, the cost of treating multiple sclerosis with mitoxantrone will be amount to 2500 rubles. for 3 months, or about 840 rubles. for the month that quite affordable.
Unfortunately, mitoxantrone may not be indicated for all forms of the disease. It also has side effects – it’s nausea, baldness, affection of an upper respiratory infection ways. It is cardiotoxic and cannot be used during pregnancy. But the most important side effect can be considered increased risk of developing leukemia (malignant bleeding), and especially at high doses, at which cumulation occurs. it dose of 80 mg per square meter. The risk of getting cancer of the blood is pretty high, 1%, and this limits the use of this tool. But you can apply it once, in a low dosage, before start treatment with Copaxone or Beta-interferons.
Tizabri is used once a month intravenously, 300 mg each. is he recommended for patients with high disease activity if before this, a full course of the drug PITRS 1 line did not give expected results. It can be applied immediately, that is, as first line medicine with aggressive multiple sclerosis. Not in In no case should it be used by patients with primary progressive or secondary progressive forms. Of course, to a person without a medical education, and even to a doctor, who have not passed the specialization in multiple sclerosis is difficult understand the features of the flow, but it is extremely important for proper therapy in anticipation of an adequate response.
When used correctly, Tizabri reduces the frequency of exacerbations by almost 70%, and a slowdown in signs of disability by 55%. Nearly 40% of patients who received tisabri for 2 years did not have increased activity of the disease. The difficulty is the fact that Tisabri infusion should be carried out only by specially trained nurses, and only in institutions where you can urgently stop severe allergic reactions. Unwanted side effects effects are the development of PML (the main minus), and opportunistic infection. Tizabri is worth about 36,000 rubles per one an injection equal to the cost of a monthly course.
This drug is tablet, and you need to use it inside, no injections or infusions are required. On the one hand it’s good and it really helps. If the patient diagnosed with a remitting form of multiple sclerosis and first-line drugs did not help, then you can go to Guilenia. It can also be used in patients with aggressive multiple sclerosis, which previously did not receive any treatment. A drug reduces the frequency of exacerbations and slows the progression disability.
However, the drug can disrupt the heart rate, cause increased atrioventricular block, increase the risk of infections, including herpes, and reduces the number of lymphocytes. therefore before the first intake of fingolimod is necessary before taking measure blood pressure and record an ECG, identify those patients who have additional risk factors, for example slow heart rate and the presence of atrioventricular block, who can get a serious complication.
After taking the drug, you need to measure the pulse every hour, after 6 hours – record an ECG, and only after a 6-hour stay in the hospital, examination and monitoring of the ECG, the patient can be released home. The second nuisance is a rather high cost. the drug. Guilenia is sold in capsules, and the monthly cost of the course is approximately 65,000 rubles.
Perhaps, at the moment, alemtuzumab is the most expensive of drugs for the treatment of multiple sclerosis. In the first year to the patient 5 infusions are given, and in the second year – 3 infusions. Only 8 infusions. Given that one bottle of concentrate for cooking is worth about 550,000 rubles., then a 2-year course of treatment will cost more than 4 million rubles.
It is prescribed not to all, but only to those patients in whom the disease is actively and aggressively, and Tisabri contraindicated. Also these are those patients with aggressive forms. multiple sclerosis, which drugs do not help for a year first line. Patients who are prescribed alemtuzumab include persons who have been treated by Tisabri for 2 years, but they have high risk of developing a serious complication such as progressive multifocal leukoencephalopathy. Exist and other indications, such as persistent disease activity, despite prior prior treatment mitoxantrone.
The drug is a monoclonal antibody, and is also significantly reduces the frequency of exacerbations by 50%, slows down the speed progression of disability. Like all strong drugs after infusion Lemtrada may be an acute reaction to infusion, thyroid damage, nephropathy. Therefore especially close monitoring is necessary in those patients who have pathology of the thyroid gland.
Finally, okrelizumab belongs to the PITRS of the second line. or Okrevus. It is administered intravenously once every six months if the patient multiple sclerosis with exacerbation, namely, remitting and secondary progressive form. It is also shown with primary progressive form. One indication will be the absence response to PITRS 1 line, a high risk of progressive multifocal leukoencephalopathy after two years of treatment Tizabri, as well as high activity of the disease after cyclophosphamide or after mitoxantrone. The drug is reliable reduces the frequency of exacerbations and prolongs the activity of the patient, and it’s expensive.
The first infusion is initially 300 mg on one day and 300 mg on Day 15, total 600 mg in 2 weeks. If the patient has tolerated the drug well, then, after 6 months, a dose of 600 mg is administered to him. how many Is Okrevus worth it? Half the standard dosage, i.e. a concentrate containing 300 mg will cost about 230,000 rubles., and each subsequent administration after 6 months, respectively 450,000 rubles.
Organizational features of the appointment of PITRS
As the names suggest, all these drugs are not familiar to the simple to a person, they are very specific. And even if the doctor spent diagnostic search and accurately established the diagnosis, type of course and the severity of multiple sclerosis, and “prescribed” the right medicine, you should not think that the medicine will immediately be to the patient assigned:
- The PITRS Appointment Commission should recommend this a drug;
- information must be submitted to the regional office health care, where the patient will be put on a waiting list (!);
- an answer should come from a health facility;
- to prescribe the drug, the patient is again examined by a neurologist (and suddenly he recovered, and this is not a joke, because ITU regularly come disabled people report that they still have no legs or hands);
- then a prescription is written, it is copied to an outpatient a map;
- the patient learns to do injections, and only then he receives the drug, if the auction took place, and he appeared in this region of the Russian Federation.
But quite often interruptions occur, and treatment should be continue. In this case, a painful replacement of one funds for another, which the patient almost always tolerates poorly. Why bad? Yes, because all the changes we have are working in one side, and sudden purchase instead of cheap patriotic means of an expensive imported drug that is well tolerated – this is from the realm of fiction. There are a lot of “pitfalls” here. For example, a drug may be purchased by the state when it is due. validity, although valid, is nearing its end. This allows write off under the tender unrealized balances that are already guaranteed not to be sold, if there is an administrative resource.
Of course, sometimes PITRS drugs should be changed abroad. IN ideally, the doctor should have several means, since one drug may go to the patient, and the second may not “go”. Finally, if the course of the disease changes, then it will be necessary vertical replacement, that is, a transfer from the first line to the second. Than the sooner this is done, the better.
Unfortunately, financial injections in the treatment of multiple sclerosis not limited to expensive specific drugs, though, of course, this is the most serious expense item, as individuals, and public health. Patients need a lot conventional medicines:
- many with multiple sclerosis have increased muscle tone, or spasticity. They are assigned Midokalm, Baclofen and Sirdalud. For anticonvulsants are also used to treat spasticity gabapentin, especially in painful forms;
- with severe spasticity, Botox or Dysport is recommended;
- in the presence of pelvic disorders and imperative urges to urination is used Driptan, Detrusitol;
- a patient with multiple sclerosis often has pain. As with neuropathic pain, gabapentin is used, finlepsin, lamotrigine, clonazepam;
- due to limited mobility, back pain occurs which bathe non-steroidal anti-inflammatory drugs;
- a large number of patients have sexual disorders, Phosphodiesterase inhibitors such as Viagra Cialis and Levitra for active life;
- it is extremely important to fight depression, for this apply modern antidepressants.
You can list drugs for a very long time, but it must be remembered that not only medicines are necessary for patients for the treatment of multiple sclerosis, but also physiotherapy, massage, and then, with the development of disability – various physical means rehabilitation.
Also vital is proper mental psychological attitude, attitude to the disease, full and prolonged sleep, which should be at least 7 hours. A patient should optimize their motor activity, and even allowed to play sports. Full employment is very important. at work as it contributes to psychological comfort.
Of course, family support is important because at present medicine has reached such a stage of development that a woman who is sick multiple sclerosis, can become pregnant and give birth, because it is not affects the risk of exacerbation, and the child does not have multiple sclerosis transmitted. It is important to remember that with proper treatment and timely relief of exacerbations can put off symptoms this disease for many years and live a full and active a life.
Attention! This rating is subjective, not advertising and does not serve as a guide to the purchase. Before the purchase consultation with a specialist is necessary.