bmj.com Rapid Responses for Murray, 332 (7540) 525-527

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CLINICAL REVIEW:
T J Murray
Diagnosis and treatment of multiple sclerosis
BMJ 2006; 332: 525-527 [Full text]

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Rapid Responses published:

Potential changes in management for clinically isolated episode of optic neuritis: Peter D Cackett, James Cameron, Harry Bennett (5 March 2006)

Ocular manifestations of multiple sclerosis: Mohammad T Masoud (5 March 2006)

Multiple Sclerosis review by T.J. Murray: marc allewaert (5 March 2006)

M.S.and Gluten: Harvey J. Marrable (6 March 2006)

Multiple sclerosis and Cannabinoids: Sergio Abanades, Magi Farre. MD. Clinical Pharmacologist. Institut Municipal Investgaci� M�dica. UAB. (14 March 2006)

Potential changes in management for clinically isolated episode of optic neuritis 5 March 2006

Peter D Cackett,
Ophthalmology SpR
Princess Alexandra Eye Pavilion, Edinburgh, EH3 9HA,
James Cameron, Harry Bennett
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Re: Potential changes in management for clinically isolated episode of optic neuritis

Professor Murray highlights the recent advances in diagnosis and management of multiple sclerosis.1 This is of particular importance for the management of a clinically isolated episode of optic neuritis. Current UK ophthalmological management of a unilateral episode of typical optic neuritis in general is not to investigate or to treat.2 However with the development of the McDonald criteria for diagnosis of multiple sclerosis (MS) 3 and advances in MRI imaging of MS lesions,4 there is potential for early diagnosis of MS. This is important as new therapies that become available such as recombinant interferon-beta-1a may reduce the development of clinically definite MS. 5 Future best clinical practice in the management of acute optic neuritis may therefore be to investigate all patients in order to identify those with MS who would benefit from early treatment.
1. Murray TJ. Diagnosis and treatment of multiple sclerosis BMJ 2006;332:525-527
2. Ghosh A, Kelly SP, Mathews J, Cooper PN, Macdermott N. Evaluation of the management of optic neuritis: audit on the neurological and ophthalmological practice in the north west of England. J Neurol Neurosurg Psychiatry. 2002 Jan;72(1):119-21.
3. McDonald WI, Compston A, Edan G, Goodkin D, Hartung HP, Lublin FD, et al. Recommended diagnostic criteria for multiple sclerosis: guidelines from the international panel on the diagnosis of multiple sclerosis. Ann Neurol 2001;50: 121-7.
4. Magnetic resonance imaging advances in multiple sclerosis. J Neuroimaging. 2005;15(4 Suppl):5S-9S.
5. Soderstrom M. Multiple sclerosis: rationale for early treatment. Neurol Sci. 2003 Dec;24 Suppl 5:S298-300.
Competing interests: None declared

Ocular manifestations of multiple sclerosis 5 March 2006

Mohammad T Masoud,
Senior House Officer, Ophthalmology
Stirling Royal Infirmary, Stirling. UK. FK8 2AU
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Re: Ocular manifestations of multiple sclerosis

I found the article on multiple sclerosis by Professor Murray very informative [1]. Multiple sclerosis (MS) is of special interest to ophthalmologists as ocular manifestations are sometimes the first sign of this disease[2]. These include optic neuritis, internuclear ophthalmoplegia, ocular motor cranial nerve palsies, trigeminal and facial nerve palsies, nystagmus, pars planitis and retinal periphlebitis [2,3,4]. These conditions may predict additional demyelinating events and therefore their recognition is very important.
Prof. Murray has also described the current trends in the treatment of MS. I would like to mention here the Optic Neuritis Treatment Trial (ONTT), a randomized 15-centre trial of 457 patients to assess the effects of corticosteroids in optic neuritis [5,6]. The results of ONTT showed that intravenous methylprednisolone hastened the recovery of visual function following optic neuritis without significantly improving the long -term final visual acuity. The trial also showed that while intravenous steroids reduced the incidence of symptomatic multiple sclerosis, oral steroids were associated with an increased recurrence of optic neuritis.
The treatment of intermediate uveitis due to MS is indicated when the visual acuity is 6/12 or less due to cystoid macular oedema. This includes systemic and posterior sub-Tenon steroids, cryptherapy and pars plana vitrectomy [7].
Symptomatic patients with long-standing ocular motility disorders and ocular cranial nerve palsies may benefit from prisms or corrective surgery on extraocular muscles.
References:
1. T J Murray. Diagnosis and treatment of multiple sclerosis. BMJ 2006;332:525-7.
2. Chen L, Gordon LK. Ocular manifestations of multiple sclerosis. Curr Opin Ophthalmol. 2005 Oct;16(5):315-20.
3. J J Kanski. Clinical Ophthalmology, A Systematic Approach, 5th Edition. Butterworth-Heinemann 2003;pp.601-2.
4. Cerovski B, Vidovic T, Petricek I, Popovic-Suic S, Kordic R, Bojic L, Cerovski J, Kovacevic S. Multiple sclerosis and neuro-ophthalmologic manifestations. Coll Antropol. 2005;29 Suppl 1:153-8.
5. Beck RW, Cleary PA, Anderson MM, et al. A randomized, controlled trial of corticosteroids in the treatment of acute optic neuritis. New Eng J Med 1992; 326:581-88.
6. Beck RW, Cleary PA, Trobe JD, Kaufman DI, Kupersmith MJ, Paty DW, Brown CH, and the Optic Neuritis Study Group. The effect of corticosteroids for acute optic neuritis on the subsequent development of multiple sclerosis. New Eng J Med 1993; 329:1764-69.
7. J J Kanski. Clinical Ophthalmology, A Systematic Approach, 5th Edition. Butterworth-Heinemann 2003;pp.306-7.
Competing interests: None declared

Multiple Sclerosis review by T.J. Murray 5 March 2006

marc allewaert,
neurologist
8500 Kortrijk - Belgium
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Re: Multiple Sclerosis review by T.J. Murray

A very welcome and up to date article by T.J Murray about multiple sclerosis but why not mention the 2005 revisions of the diagnostic McDonnald Criteria instead of the 2001 ?
Competing interests: None declared

M.S.and Gluten 6 March 2006

Harvey J. Marrable,
almost retired Psychiatrist in private peactice
Wamberal N.S.W. 2260 Australia
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Re: M.S.and Gluten

In 1961 at the age of 33 I suffered my first attack of M.S. Hemiataxia leading to hospitalisation, cerbral angiograms and resolving in 4 weeks without any treatment. One year later I suffered right homonomous hemianopia leading to angiograms of the remaining cerebral arteries and pneumo-encephalogram(not pleasant) and resolving in 4 weeks. After another year optic neuritis also resolving quickly.
I treated the second attack with A.C.T.H., the third with cortizone. At this time I decided to leave General Practice and train in Psychiatry. I read in the BMJ a letter by a Melbourne Doctor called Shatin who gave a very well reasoned argument that MS was (sometimes) due to Gluten sensitivity. It made sense to me and was an alternative to sitting and waiting for my wheel chair. Also it did not forbid tobacco or alcohol. I then entered a 20 year remission with a few trivial and transient symptons only recognised in retrospect.
My next relapse was in 1981, weakness of one leg, then in 1985 a Bell's Palsy and since then slow deterioration of balance and a stable 'neurological bladder'.
Now at 77 I work one day per week and am pretty fit for my age. I survived meningococcal meningitis this year and had my first ever MRI scan which confirmed the diagnosis of longstanding MS.
Naturally I have read the journals for the last 60 years. Gluten has been debunked in relation to MS but in the BMJ VOLUME 318 26th June 1999 page 1710 is a paper relating neurological manifestations of Gluten sensitivity.
I am very glad that expensive medications were not available when I went on the gluten free diet.
Competing interests: None declared

Multiple sclerosis and Cannabinoids 14 March 2006

Sergio Abanades,
MD. Clinical Pharmacologist
Institut Municipal Investgaci� M�dica. UAB. 08003. Barcelona.,
Magi Farre. MD. Clinical Pharmacologist. Institut Municipal Investgaci� M�dica. UAB.
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Re: Multiple sclerosis and Cannabinoids

We read with much interest the article by TJ Murray on diagnosis and treatment of multiple sclerosis (MS) (1). Surprisingly, the possible role of cannabinoids in the treatment on MS is not even mentioned. Nevertheless, there is growing evidence supporting the use of cannabinoids for symptom relief in MS. In these patients, treatment with cannabinoids has been shown to be clinically effective in the control of spasticity, bladder function, tremor and pain (2-5). In this line, Sativex, an oro- mucosal spray containing both delta-9-tetrahydrocannabinol (THC) and cannabidiol (CBD) in 1:1 ratio and <5% of other cannabinoids, has recently been approved in Canada as an add-on therapy for MS associated neuropathic pain (6). On the other hand, evidence of a possible role of cannabinoids on neuroprotection in MS is increasing. Both administration of cannabinoids and manipulation of the endocannabinoid system have been associated with neuroprotective effects in animals models of MS (7). In fact, due to these evidences in animals and some clinical data pointing to a possible effect beyond symptom amelioration in humans (8), some clinical trials are beginning in order to evaluate the potential effect of cannabinoids on clinical disability in MS patients.
1.Murray TJ. Diagnosis and treatment of multiple sclerosis. BMJ. 2006;332:525-27.
2.Zajicek J, Fox P, Sanders H, Wright D, Vickery J, Nunn A, Thompson A; UK MS Research Group. Cannabinoids for treatment of spasticity and other symptoms related to multiple sclerosis (CAMS study): multicentre randomised placebo-controlled trial. Lancet. 2003;362:1517-26.
3.Rog DJ, Nurmikko TJ, Friede T, Young CA. Randomized, controlled trial of cannabis-based medicine in central pain in multiple sclerosis. Neurology. 2005;65:812-9.
4.Wade DT, Makela P, Robson P, House H, Bateman C. Do cannabis-based medicinal extracts have general or specific effects on symptoms in multiple sclerosis? A double-blind, randomized, placebo-controlled study on 160 patients. Mult Scler. 2004;10:434-41.
5.Vaney C, Heinzel-Gutenbrunner M, Jobin P, Tschopp F, Gattlen B, Hagen U, Schnelle M, Reif M. Efficacy, safety and tolerability of an orally administered cannabis extract in the treatment of spasticity in patients with multiple sclerosis: a randomized, double-blind, placebo- controlled, crossover study. Mult Scler. 2004;10:417-24.
6.Sibbald B. Conditional okay for cannabis prescription drug. CMAJ. 2005;172:1672.
7.Jackson SJ, Diemel LT, Pryce G, Baker D. Cannabinoids and neuroprotection in CNS inflammatory disease. J Neurol Sci. 2005;233:21-5.
8.Zajicek JP, Sanders HP, Wright DE, Vickery PJ, Ingram WM, Reilly SM, Nunn AJ, Teare LJ, Fox PJ, Thompson AJ. Cannabinoids in multiple sclerosis (CAMS) study: safety and efficacy data for 12 months follow up. J Neurol Neurosurg Psychiatry. 2005;76:1664-9.
Competing interests: None declared