Living Well With Multiple Sclerosis

Understanding Multiple Sclerosis in the Indian Context

Multiple Sclerosis (MS)—a chronic autoimmune disease where the immune system attacks myelin (nerve insulation) in the brain and spinal cord—affects 1 in 1,000 Indians. At Ajuda Hospitals, our MS Clinic delivers early diagnosis with MRI protocols, disease-modifying therapies (DMTs) to reduce relapses, acute relapse management, and comprehensive symptom support.

MS typically strikes young adults (20-40 years) with episodes (relapses) of vision loss, numbness, weakness, or balance problems, followed by partial or complete recovery. Relapsing-remitting MS (RRMS) accounts for 85% of cases at diagnosis. Without treatment, 50% progress to secondary progressive MS (SPMS) with steady worsening. Disease-modifying therapies reduce relapse rates by 30-70%, slow disability progression, and preserve quality of life.

Indian MS patients face unique challenges: delayed diagnosis (symptoms attributed to "weakness" or stress), limited access to expensive DMTs, and lack of awareness. We provide financial counseling for insurance authorization (Ayushman Bharat, Aarogyasri), telemedicine for remote monitoring, and education in Telugu, Hindi, Urdu, and English.

When to Consult Our MS Specialists

If you've had one episode (clinically isolated syndrome), early MRI and DMT initiation can delay or prevent second attack—formal MS diagnosis.

Our Diagnostic Approach

Clinical History & Neurological Exam

History: Document attacks (optic neuritis, transverse myelitis, brainstem symptoms). Each lasting >24 hours, separated by ≥30 days (dissemination in time).

Exam: Test for pyramidal signs (weakness, hyperreflexia, Babinski), sensory deficits (vibration, pinprick), cerebellar signs (ataxia, intention tremor, dysmetria), brainstem (internuclear ophthalmoplegia, nystagmus), visual (red desaturation, RAPD).

MRI Brain & Spine

Protocol: T1 pre/post-contrast, T2, FLAIR sequences.

MS Lesions:

• Location: Periventricular (along ventricles), juxtacortical (near cortex), infratentorial (brainstem, cerebellum), spinal cord.
• Appearance: Ovoid, perpendicular to ventricles ("Dawson fingers"), T2 hyperintense.
• Gadolinium Enhancement: Indicates active inflammation (lesion <6 weeks old).

McDonald Criteria 2017: Diagnosis requires dissemination in time (≥2 attacks OR 1 attack + MRI with simultaneous enhancing and non-enhancing lesions) and space (lesions in ≥2 of 4 CNS regions).

CSF Analysis (Lumbar Puncture)

Indications: MRI atypical or incomplete for diagnosis.

Findings:

• Oligoclonal Bands: Present in CSF but not serum (95% of MS patients). Indicates intrathecal antibody production.
• Elevated IgG Index: Intrathecal IgG synthesis.
• Mild Lymphocytic Pleocytosis: <50 WBCs (higher suggests infection or NMOSD).

Rule Out MS Mimics

Neuromyelitis Optica Spectrum Disorder (NMOSD): Aquaporin-4 antibody positive; severe optic neuritis, longitudinally extensive transverse myelitis (≥3 vertebral segments). Different treatment (rituximab, not interferon).

ADEM (Acute Disseminated Encephalomyelitis): Monophasic, post-infectious, encephalopathy. Pediatric or young adults.

Vasculitis, Behçet's, Sarcoidosis: Systemic symptoms, inflammatory markers.

Treatment Pathways

Acute Relapse Management

Protocol:

1. High-Dose IV Methylprednisolone: 1g daily x 3-5 days. Speeds recovery; does NOT affect long-term disability.
2. Plasma Exchange (PLEX): If steroid-refractory (no improvement after 5 days). Removes autoantibodies; 5-7 sessions over 2 weeks.
3. Supportive Care: Physical therapy for weakness, bladder catheterization if retention, bowel regimen, pain management.

Outcome: Most recover within 4-12 weeks; residual deficits possible.

Disease-Modifying Therapy (DMT)

Goal: Reduce relapses, slow disability progression, prevent new MRI lesions.

First-Line Injectable:

• Interferon Beta-1a (Avonex 30mcg IM weekly, Rebif 44mcg SC 3x/week): Reduce relapses 30%. Side effects: flu-like symptoms (pre-medicate with acetaminophen), injection site reactions, depression (monitor PHQ-9).
• Glatiramer Acetate (Copaxone 20mg SC daily): Mimics myelin, diverts immune attack. Side effects: injection site reactions, lipoatrophy, post-injection systemic reaction (flushing, palpitations—benign).

First-Line Oral:

• Teriflunomide (Aubagio 14mg daily): Pyrimidine synthesis inhibitor. Side effects: hair thinning (reversible), diarrhea, liver toxicity (monitor ALT). Teratogenic—contraception mandatory; washout 2 years or cholestyramine if pregnancy desired.
• Dimethyl Fumarate (Tecfidera 240mg bid): Nrf2 pathway activator. Side effects: flushing (dose with aspirin), GI upset, lymphopenia (monitor CBC; stop if <500).

High-Efficacy DMTs (For aggressive MS or inadequate response):

• Natalizumab (Tysabri 300mg IV monthly): α4-integrin blocker; prevents immune cells crossing BBB. Efficacy: 68% relapse reduction. Risk: PML (progressive multifocal leukoencephalopathy) if JC virus positive—stratify risk, MRI surveillance every 3-6 months.
• Fingolimod (Gilenya 0.5mg daily): S1P receptor modulator; sequesters lymphocytes in lymph nodes. Efficacy: 54% relapse reduction. Monitoring: First-dose observation (6 hours—bradycardia risk), ophthalmology (macular edema), VZV vaccination if seronegative.
• Ocrelizumab (Ocrevus 600mg IV every 6 months): Anti-CD20 monoclonal antibody; depletes B cells. Efficacy: 47% relapse reduction vs interferon; only DMT for PPMS. Risk: Infusion reactions (pre-medicate), infections (screen hepatitis B, immunoglobulins).

Symptom Management

Spasticity: Baclofen 10-80mg/day, tizanidine 4-32mg/day, botulinum toxin for focal spasticity.

Neuropathic Pain: Gabapentin 900-3600mg/day, pregabalin 150-600mg/day, duloxetine 60mg/day.

Bladder Dysfunction: Anticholinergics (oxybutynin, solifenacin) for urgency; intermittent self-catheterization for retention; urology referral for refractory cases.

Fatigue: Amantadine 100mg bid, modafinil 200mg AM (off-label); energy conservation strategies (pacing, scheduled rest).

Depression/Anxiety: SSRIs (sertraline, escitalopram); cognitive-behavioral therapy.

Rehabilitation & Wellness

Physical Therapy: Gait training, balance exercises, stretching for spasticity. Aquatic therapy (cool water prevents heat-induced symptom worsening—Uhthoff's phenomenon).

Occupational Therapy: ADL strategies, adaptive equipment (walker, ankle-foot orthosis), home modifications.

Cognitive Rehabilitation: Memory strategies, attention training for MS-related cognitive impairment (40-60% affected).

Lifestyle:

• Exercise: Aerobic 30 min, 3-5x/week (improves fatigue, mood, fitness).
• Vitamin D: Supplement to >30 ng/mL (low D linked to higher relapse risk).
• Smoking Cessation: Smoking accelerates MS progression.
• Stress Management: Yoga, meditation (stress may trigger relapses).

What to Expect: Your Care Journey

First Visit (90 min)

Detailed history, neurological exam, review outside MRI (if available). Order brain + spine MRI with contrast. Discuss diagnosis, prognosis, DMT options, family planning considerations.

Follow-Up (2 weeks)

Review MRI, confirm MS diagnosis per McDonald criteria. CSF if needed. Start DMT—teach self-injection or schedule first infusion. Baseline labs (CBC, CMP, hepatitis screen).

3-Month Check

Assess DMT tolerability, side effects. Reinforce adherence. Symptom management as needed. Encourage exercise, vitamin D.

Annual MRI

Compare to baseline—look for new or enlarging T2 lesions, gadolinium enhancement (disease activity). If stable → continue current DMT. If breakthrough disease (relapse or new MRI lesions) → escalate to high-efficacy DMT.

Every 6-12 Months

EDSS (Expanded Disability Status Scale) scoring to track disability. Screen for depression, cognitive impairment. Update vaccinations (avoid live vaccines on DMT). Financial/insurance review for DMT coverage.

Technology & Innovation

High-Resolution 3T MRI

Superior lesion detection vs 1.5T. Volumetric analysis tracks brain atrophy (marker of neurodegeneration). Standardized imaging enables comparison across time—critical for treatment decisions.

Optical Coherence Tomography (OCT)

Non-invasive retinal imaging measures retinal nerve fiber layer (RNFL) and ganglion cell layer thickness. Thinning correlates with MS severity and predicts disability progression. Useful for monitoring subclinical disease activity.

Telemedicine MS Clinic

• Quarterly video consults for stable patients.
• Review symptoms, side effects, adherence.
• Coordinate local MRI; neurologist reviews remotely.
• In-person visits for annual comprehensive exam, infusions (natalizumab, ocrelizumab).

Outcome: Maintains continuity for patients in Warangal, Karimnagar, Nalgonda; reduces travel burden.

Preventing Complications

Relapses: Prevented by DMT adherence, vitamin D, smoking cessation, stress management. Vaccinations (flu, COVID) safe and recommended—infection can trigger relapse.

Disability Progression: Early, consistent DMT use is key. High-efficacy DMTs for aggressive disease. Physical therapy maintains mobility.

Infections on Immunotherapy: Vaccinate pre-DMT (live vaccines contraindicated on most DMTs). PML screening for natalizumab (JC virus testing). Prompt treatment of UTIs, respiratory infections.

Pregnancy Risks: Plan with neurologist. Stop teratogenic DMTs (fingolimod, teriflunomide) months before conception. Natalizumab or ocrelizumab may continue until pregnancy confirmed. Relapse risk lowest during pregnancy, increases postpartum—restart DMT immediately.

Why Ajuda for MS Care?

Take the First Step

If new symptoms: Call 9010550550 for urgent evaluation. Early DMT initiation after first attack reduces risk of second attack by 50%.

If diagnosed but not on DMT: Request DMT consultation. Treatment is most effective early—delays allow irreversible damage.

If breakthrough disease on current DMT: Discuss escalation to high-efficacy therapy. Ocrelizumab, natalizumab can control aggressive MS when first-line fails.

Ajuda Hospitals: Where MS meets cutting-edge treatment, and hope is backed by evidence.