Study of the Central Nervous System and the Peripheral nervous system

Introduction

Human body consists of different systems among them nervous system is one, it is composed of two parts they are-

The Central nervous system: It is composed of brain and spinal cord; it transmits sensory information to the Central Nervous System from sense organ.

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The Peripheral nervous system: It connects the central nervous system to the glands, sensory organs, and muscle through different nerves.

A nerve in our body is covered by a layer of protective sheath it is known as myelin. Myelin is a fatty substance made up of protein it provides protection to the nerves. It helps in the transmission of nerve impulse between the brain and other parts of the body by maintaining the speed of impulses. Each neuron consists of long thread of cytoplasm known as axon; it helps to transport messages from one part of the body to another it is a protected by the sheath of myelin. Axon conducts impulses at a very high rate and allows the transfer of information between neurons to assist motor function and sensory perception. As we know human beings with healthy immune system can fight with disease in proper way in compared with the people whose immune system is weak. Sometime immune system of human beings gets weaker by the different factors such as virus, bacteria, genetic as well as environment. Damage to the immune system causes the white blood cell to attack own healthy tissue and large number of immune cells enter into the central nervous system this is directed against the body’s own tissue it is known as autoimmune disease. Presence of large number of immune cells causes an inflammation this leads to damage of the myelin sheaths that protect the nerves and helps in the transmission of electric impulse in a great speed between the neurons.

Due to the inflammation nerves gets separated from myelin this is known as demyelination then scarring (it is known as sclerosis) occurs at the place where nerves has been separated from myelin. Due to this plaques and inflammation are formed in this place and they vary in number (multi) this is known as multiple sclerosis this cause central nervous system to be affected. As a result delay in transmission of electric impulses between the parts of the body occurs. This leads in slowing day to day activity such as moving, speaking and so on.

Many people gets affected by the multiple sclerosis around 85,000 people are affected by this disease in UK. Symptoms occur between the age of 20 and 40. But this disease has been found in theage of 15 this has been considered as an early age and 60 as later age. Women get affected two or three times more than men as well as their is chance that women get affected in early phase of life in compare to men. This disease can affect white race people in compare to other race. Multiple sclerosis affects Asian, Africanand Hipic people rarely.

Different people face different symptoms it depends on how myelin or axon is damaged thus the symptoms differs from person to person. If a symptom gets more worse it is known as relapse it is not predictable and the symptoms will last minimum for twenty four hours. If the symptoms aren’t seen or gets vanished it is known as remissions. Some common symptoms of this disease are-

Feeling weak- Weakness is the common symptoms in multiple sclerosis, many people face this more time.

Muscular spasms- This is also known as spasticity, in this symptom contraction occur in muscle.

Blurred or double vision- Nerve that controls eye movement is damaged in this symptom. Due to this full range of movement can’t be covered and double vision occurs.

Slurred speech- This is known as dysarthria, in this nerve which controls muscles linked with speaking gets decreased and the patient gets problem related to the speech.

Tremor: In this shaking occurs various part of the body and they aren’t controllable. This is caused by the damage to the different part of the nerve pathways which helps in movement and co-ordination.

Problem related with emotional- People face different problems related with emotion such as depression and anxiety.

Pain- this is divided into two types they are

Neuropathic pain-Nerve fibre gets damaged in this type of pain.

Musculoskeletal pain- Pain occurs in muscle.

Ataxia: Patient can’t control voluntary muscle movement they feel difficult to control the movement. Person feels weak when walking and difficult to manage balance when standing.

Bladder and bowel problems: In this patient face the problem related with overactive bladder or underactive bladder.

Constipation or urgency is the problem connected with the bowel.

Cognitive problem: This is related with the thinking process, patients feel problem with remembering and learning any skilled work.

As many people feel pain due to this disease, use of painkillers would be great help for the people suffering from this disease. If pain occurs due to damage in the nerve fibre then it is known as neuropathic pain. Medicine such as Gabapentin, Pregabalin, Amitriptyline, Imipramine and carbamazepine can be used to treat neuropathic pain.

Gabapentin: Dose for neuropathic pain for adult over 18 years –

300 mg once a day on 1st day and 300 mg twice a day on 2nd day and then 300 mg 3 times daily on 3rd day can be given at the difference of every 8 hours, or 300 mg 3 times daily can be given on 1st day initially, the dose can be increased according to response in steps of 300mg daily (in 3 divided dose) every 2-3 days to max 3.6 gm daily. It is administered orally.

Side effects of this medicine are feeling mouth dry, inflammation of gum, feeling burning like sensation in the mouth, dysarthria (difficult in articulation), nystagmus (involuntary eye movement), tremor, hepatitis, urinary incontinence, ataxia, fatigue, dizziness, blood glucose fluctuations in patients with diabetes, acute renal failure and alopecia (loss of hair).

Gabapentin works by increasing the level of GABA (Gamma Amino Butyric Acid) in the brain and inhibit the Central Nervous System.

Pregablin: Dose for neuropathic pain for the adult over 18 years, 150 mg is given initially in 2-3 divided doses, it can be increased to maximum after 7 days that is 600 mg daily in 2-3 divided doses. It is administered orally.

Side effects of this medicine includes dry mouth, constipation, nausea, vomiting, dizziness, euphoria, thrombocytopenia, swelling in joint, menstrual disturbances, pain in the breast, pancreatitis, change in sexual function and flatulence.

It also works by increasing the level of GABA (Gamma Amino Butyric Acid) in the brain and inhibit the Central Nervous System.

Amytriptyline: for the patient suffering from neuropathic pain initially ( 10- 25) mg daily at night it should be increased to 75 mg daily if necessary, higher dose should be administered under the supervision of specialist. It is administered orally.

Side effects of Amytriptyline are as dry mouth, sedation, vision becomes unclear, constipation, nausea, difficulty in urination, tachycardia and arrhythmias

It works by inhibiting the neuronal reuptake of nor adrenaline in the Central Nervous System; it also inhibits the reuptake of serotonin (5-HT). Prevention of the reuptake of this monoamine neurotransmitter cause to increase nerve impulse outside the brain cells thus increasing the availability of monoamines in the brain inhibits the depression.

Co-codamol 30/500- this is an analgesic medicine this contains 30 mg codeine phosphate and 500 mg paracetamol it is used for severe pain.

Codeine within it binds to the opioid receptors in the Central Nervous System and there is response to painful stimuli and the severity of pain is decreased.

Paracetamol works by inhibiting the prostaglandin synthesis which stimulates pain in the body. Patients feel less pain when prostaglandin synthesis is inhibited.

Dose: 1-2 tablets every 4 hours, maximum 8 tablets daily.

Side effects: feeling dizzy, headache, mouth become dry, feeling pain while urinating, nausea, cramps in the stomach, sore throat

It is administered orally.

Carbamazepine: It is used to treat trigeminal neuralgia the pain in the regions of face. Trigeminal nerve can be found in three areas of the face they are the forehead, cheek and the jaw.

Dose of carbamazepine: initially 100 mg 1-2 times daily should be increased according to response. Usual dose 200 mg 3-4 times daily, up to 1.6 g daily.

Side effects: diplopia, constipation or diarrhoea, anorexia, fever, oedema, arthralgia, leucopoenia, hepatitis, Jaundice, depression, headache, drowsiness

It is administered orally.

Sometimes pain occurs in the body due to stiffness and muscle spasms pain caused by this is known as musculoskeletal pain. For the treatment caused by pain in muscle medicine such as Baclofen, Dantrolene can be used as they are muscle relaxant medicine.

Baclofen: The dose of Baclofen is 5 mg 3 times daily with or after food, it can be increased gradually maximum 100 mg daily (it should be discontinued if benefit is not seen after 6 weeks).

Side effects: dry mouth, hypotension, respiratory or cardiovascular depression, sedation, drowsiness, hallucinations, nightmare, urinary disturbance, nystagmus, abdominal pain and insomnia.

It acts in the spinal cord and reduces nerve impulse from spinal cord to skeletal muscle. As there is decrease in the severity of muscle spasm; due to decrease in the spasms pain is also reduced.

Dantrloene: Dantrolene show its action directly on the muscle, so it is known as direct acting muscle relaxant. It blocks the release of calcium ion from sarcoplasmic reticulum (it is the muscle where calcium is released and stored and it causes muscle to contract and relax.) As the release of calcium ion is blocked contraction of muscle won’t occur.

Dose: Initially 25 mg daily and it may be increased at weekly intervals to max 100 mg 4 times daily; usual dose is 75 mg 3 times daily.

It is administered orally.

Side effects: drowsiness, fatigue, weakness, fatigue, bradycardia, confusion, abdominal pain, nervousness, increased urinary frequency, respiratory depression, fever and disturbance in the visual.

Steroids are the hormone and it occurs naturally in the human beings body. Steroids suppress the immune system of the body and inflammation is reduced in the Central Nervous system. Due to this immune system within the body can’t damage myelin sheath which covers neurons and protect it. Steroids with high dose are prescribed because it increases up the improvement from a relapse. Some commonly used steroids are as follows

Prednisolone: It is given orally initially up to 10-20 mg daily

Methylprednisolone: Orally it is given 2-40 mg daily

By infusion it is given up to 1gm daily for 3 days.

Dexamethasone: Orally it is given usual range of 0.5-10 mg daily for the adult, for the child 10-100 mg/kg daily

Different problem can be seen if a steroid is used for long term, problem such as

Thinning of the skin,

Osteoporosis,

Blood pressure gets increased this can make the condition of diabetes patient make worse

Change in the mood,

Increased in the weight,

Patients feel the taste of metallic in the mouth,

Increased in heart beat,

Ankles gets swollen,

Women will face the problem of irregular menstruation,

Change in sleep style occurs,

Stomach gets upset,

Delay in healing of the wound,

There is more chance of suffering from infections,

Changes occur in the colour of the skin

These can be reduced by carrying some activities in the life such as –

As higher strength drug can cause different problem it should be told to the doctor by the patient so that doctor can prescribe medicine with low dose.

Corticosteroid can be taken alternatively so that there is no need of taking daily, prescriber can prescribe medication which can be used for short time.

As this medication causes increase in weight patient should carry out some exercise daily, patient can deduct the amount of calories they are having and thus change in eating habits.

Osteoporosis is also one of the problems related to the long term use of corticosteroids, patient can take food rich in calcium or vitamin D and they can also have the supplement of calcium or vitamin D so that the bone will be stronger. Prescriber can prescribe the medicine which contains Bisphosphonates such as Alendronic acid it reduces the rate of turnover of the bone which can be the treatment for osteoporosis.

Different symptoms occur in the body due to this disease symptom such as

Overactive bladder- to overcome this problem oxybutynin or toltrerodine can be used. As it is anticholinergic drug, it blocks the release of acetylcholine and the relaxation of smooth muscle of the bladder occurs then the patient won’t have the problem of urinary incontinence.

Urine retention: Patients suffering from urine retention are catheterised normally.

Fatigue and depression- This is also one of the leading problem that the patient of multiple sclerosis are facing.

Medicine such as fluoxetine which is an antidepressant helps in managing the fatigue. As it is antidepressant it blocks up the reuptake of serotonin and raises its level outside the nerve ending. As the level is increased there won’t be any depression and the patient feel excitement which also leads patient to be active and get rid from fatigue.

Sertraline is also given for the patient suffering from mild anxiety it also works by blocking reuptake of serotonin.

Sleep disorder: Modafinal is used to treat the pattern of sleep disorder it also reduces the fatigue. It increases the level of dopamine and norepinephrine by blocking the reuptake of dopamine and by inhibiting the enzyme MAO (Mono Amino Oxidase). This is enzyme it metabolizes neurotransmitters such as dopamine; serotonin and norepinephrine as this medicine inhibit the enzyme MAO, level of serotonin, dopamine and norepinephrine won’t decrease in the body. This leads patient to be free from depression, which then help patient to get rid of excessive sleepiness.

Sexual problem: As neurons get damaged in multiple sclerosis, sexual function gets affected because nerve which send message to the sexual organs don’t function properly and different problems related to sex starts to arise. About 70% women and 90% get affected due to the multiple sclerosis.

For the men

An oral medication Viagra is used, it helps to maintain erection.

Medicine which can be injected: It is injected into the base of the penis and blood flow is increased during sexual intercourse and helps to maintain erection.

Medicine related to relaxant of muscle and pain: It can also be used to treat spasms as well as the pain that occurs during the period of sexual contact.

For the women

Orally Viagra is also given to women.

Vaginal lubricants helps women to get rid from vaginal dryness, this can be bought over the counter such as K-Y jelly.

Constipation: To get rid from the constipation medicine which helps to make the stool softener such as senokot can be used, laxative can also be used.

Vertigo: Medicine such as Prochlorperazine can be used to treat vertigo in multiple sclerosis. As it is anti-emetic it prevents the nausea and vomiting.

Multiple sclerosis can be managed without the medicine as well. Doing regular exercise is beneficial to the people suffering from multiple sclerosis. Spasticity of muscle can be reduced by stretching the muscle and doing different type of exercise. Aerobic exercise such as swimming in cool water, brisk walk helps to reduce fatigue in the people suffering from multiple sclerosis. This exercise helps to get the blood pumping through the heart and it increases pulse and respiration. Having the herbal medicine such as St John’s Wort is also beneficial to the people suffering from multiple sclerosis, this is natural antidepressant. It increases the action of serotonin level in nerve pathways it also inhibits the enzymes which increases depression it also helps to maintain good immune system as it has got anti-inflammatory as well as antiviral properties it helps to the people suffering from multiple sclerosis. Infection of urinary tract can increase the relapse in multiple sclerosis so having cranberry juice would be beneficial. As people suffer from stress in multiple sclerosis it can be reduced by doing the exercise which helps us to relax. Patient should try to be comfortable by slowing down the breathe and inhaling through the nose slowly.

Patient suffering from multiple sclerosis should try to maintain healthy eating habits such as.

They should have 2 litres of water per day, having appropriate amount of green vegetables, drinks which contain caffeine such as coffee, tea etc should be avoided because it increases fatigue in the patient, red meat also should be avoided because it aggravate inflammation. Saturated fats should be avoided by the patient such as cream, margarine because it may increase the symptoms of multiple sclerosis and unsaturated fats such as olives, cornflower oil, sunflower oil and rapeseed oil can be taken by the patient. As people suffer from constipation during the multiple sclerosis, taking the food which is rich in fibre would be beneficial for them.

Disease modifying treatments are also known as immune modulating medications; it changes the activity of the immune system. It reduces the occurrence and severity of relapses as well as it prevents people from being disabled. Different types of drugs were introduced from the research such as-

Interferon beta-1a,

Interferon beta- 1b,

Glatiramer Acetate,

Natalizumb

Where, interferon beta- 1a, 1b aren’t newly modified drug whereas Natalizumb is newly modified drug it was accepted in June 2006.

Interferon beta is used in patients with relapsing, remitting multiple sclerosis. It has been used in a patient who has been suffering from active inflammatory process leading to single demyelinating. It blocks the entry of the harmful immune cells to the blood brain barrier so that harmful immune cells can’t damage the myelin sheath thus it helps to improve the function of the immune system. It is a protein and it occurs in a natural way in the body. It reduces inflammation as well as autoimmune reaction, reduction of this result in stopping of destruction of myelin.

Glatiramer acetate: It is lab made medicine and is the mixture of amino acid (small component of protein). It is used for treating relapsing remitting multiple sclerosis. It stops the entry of T cells that damage the myelin to improve thus reduces the chance of inflammation and protects the sheath of myelin which covers nerve fibres. It is injected under the skin daily.

Natalizumab: This is also disease modifying medicine and it was accepted by the European Union in June 2006. It reduces the inflammation and demyelination by stopping the migration of leucocytes into the central nervous system. It is used in the treatment of relapsing remitting multiple sclerosis. While receiving the treatment it should be supervised by the specialist.

As different research has been carried( under the experiment) out to introduce new disease modified drug some of them are as follows-

Gilenya (Fingolimod).

It is used in those patients who have been suffering from active relapsing-remitting multiple sclerosis and the use of Interferon Beta wasn’t successful. It is taken one capsule once a day, active ingredient within it is fingolimod 0.5 mg.

According to research about 52% patients were recovered from relapse by the use of this medicine incomparision to the patient who are receiving interferon beta.

This medicine works by retaining the lymphocytes in the lymph nodes, in this way the lymphocytes which cause an inflammation can’t reach to the central nervous system and myelin sheath doesn’t separated from myelin.

Cladribine

It is administered orally dosage form is tablet and is undergoing final phase trial iii. According to research by comparing patient taking cladribine and placebo, patient receiving cladribine for a period of two year relapse was reduced by 60% and the patient taking this medicine for more than three months development of disability was reduced by 30%. As this medicine is administered between 8 to 10 days in a year patient can get rid from getting injection as well as intravenous infusion regularly. This medicine wasn’t approved by the European Drug Regulator in September 2010, so this medicine is under the clinical trial it is thought that it would be available by 2012.

This medicine reduces the amount of harmful immune cells getting into the blood, so they can’t reach to the myelin sheath and myelin sheath gets protected.

Liquinimod:

This medicine is under the research for the treatment of patient suffering from relapsing remitting multiple sclerosis. This medicine regulates the entry of harmful immune cells into the central nervous system (brain and spinal cord). It is administered orally dosage form is tablets.

According to clinical trial phase ii this medicine decreases the disease by 30% when the patients were treated with this medicine for more than 6 months and the patient who are at the initial stage of this disease they get it reduced by 40%. Research on second phase iii is still ongoing.

Teriflunomide: According to research 179 people were taken in the clinical trial phase ii it was for more than 36 weeks. A drug with 2 different strength that is 7mg and 14 mg were considered and was compared with placebo. Result shows that higher dose helps to reduce relapse by 67% and lower dose reduce the symptoms by 39%.

Studies related to phase iii shows that it is comparing the benefit of this medicine in relapsing multiple sclerosis in compared to placebo and interferon beta 1a.

As lymphocytes damage myelin sheath and cause multiple sclerosis. This medicine inhibits the division of this cell rapidly and it can’t reach to the blood and inflammation wouldn’t occur.

It is administered orally as a tablet.

BG-12:

This medicine was compared to placebo in those patients suffering from relapsing remittig multiple sclerosis. The study was carried for more than 24 weeks and the data shows that relapse rate was reduced by 32% but it wasn’t considered significant and it is under the experiment phase iii.

It is taken orally as tablets and two or three times a day.

Reference:

Online References:

www.mult-sclerosis.org/howms.html

www.netdoctor.co.uk

www.nhs.uk

www.mstrust.org.uk

www.ukmi.nhs.uk

Book refrences

Flinton Christine C raggs(2006) living with multiple sclerosis, London, Sheldon press.

Sctt N William and Mc Grath Deirdre (2009), made Incredibly Nursing Pharmacology

Martin John (2009) BNF, 57th edition, London, Royal Pharmaceutical Society.

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