New Treatment Approach Can Improve Exhaustion in Multiple Sclerosis

Managing fatigue is a significant burden in multiple sclerosis.

Being too beat to think, work, or sometimes even walk, many patients with multiple sclerosis (MS) find fighting fatigue a major burden.

To lighten that load, a group of German experts have scrubbed the literature to review the latest findings on the excessive tiredness that afflicts 80% of MS patients. They then used these findings and earlier guidelines to craft an individualized approach to treatment, which they call the Berlin Treatment Algorithm.

“Fatigue is a major reason for early retirement, reduced employment, and poor quality of life in people with MS,” Christian Veauthier MD, a neurologist at the Interdisciplinary Center for sleep medicine at the Universitatsmedizin Berlin, and his co-authors wrote in a paper published in the US last month.

Although studies find several suspected causes for the association of fatigue with MS, the underlying mechanisms are not well understood, according to Veauthier and his colleagues. In addition, there are no formally approved medications for MS-related fatigue. A further complication is that tiredness and fatigue may be “unspecific indicators of many other diseases (including depression, sleep disorders, anemia, renal failure, liver diseases, chronic obstructive pulmonary disease, drug side effects, recent MS relapses, infections, nocturia [excessive night time urination], cancer, thyroid hypofunction, lack of physical exercise),” they wrote.

Veauthier and his team’s goal was to “establish an individualized therapeutic strategy that factors in existing comorbid disorders” that could become a practical treatment map for physicians. The algorithm’s strategy follows the 1998 MS Council for Clinical Practice Guidelines. The algorithm’s first step is to rule out or address potential confounders. It recommends blood tests for anemia, thyroid dysfunction, renal and hepatic insufficiency, infections, and vitamin D deficiency.

Similarly testing should be done to rule out pulmonary problems. To check on the status of the patient’s MS, the algorithm calls for a neurological exam and an MRI. A check also should be done for a history of using sedative drugs. A diagnostic interview comes next to identify any potential causes of the fatigue, such as depression or sleep disorders.

Veauthier and his colleagues place special emphasis on taking a particularly close look at the possibility of sleep disorders, such as restless leg syndrome, sleep apnea, and insomnia. The algorithm also recommends ways to assess and treat them. In an earlier study, Veauthier found that 96% of MS patients reporting problems with fatigue had a sleep disorder. For depression, the algorithm recommends psychotherapy and optional psychopharmacology, such as selective serotonin reuptake inhibitors (SSRIs).

“Cogntive behavioral therapy and mindfulness-based interventions have shown efficacy in improving depressive disorders in MS,” the co-authors added.

Despite the lack of regulatory approval for drug treatment for MS-related fatigue, the algorithm notes several drugs that might be effective: vitamin D, modafinil, amantadine, and carnitine and for fatigue that inhibits walking, frampridine. As a last step if the fatigue continues, patients should try Cognitive Behavior Therapy (CBT) or try aerobic exercise or resistance training on their own or with the help of physical therapy or rehabilitation experts, according to the algorithm.

Although treating the fatigue that burdens MS patients is challenging, “a comprehensive approach including self-management strategies, rehabilitation, CBT, and the treatment of underlying sleep disorders and potentially other comorbidities is reasonable,” the authors’ paper concluded.

The paper was published in the November 24, 2016, EPMA Journal, The Berlin Treatment Algorithm: recommendations for tailored innovative therapeutic strategies for multiple sclerosis-related fatigue.