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 Table of Contents  
REVIEW ARTICLE
Year : 2021  |  Volume : 10  |  Issue : 3  |  Page : 160-164

Multiple Sclerosis in Saudi Arabia: A literature Review


1 Medical Intern, College of Medicine, Taif University, Taif, Saudi Arabia
2 Department of Surgery, College of Medicine, Taif University, Taif, Saudi Arabia

Date of Submission11-Nov-2021
Date of Acceptance18-Nov-2021
Date of Web Publication6-Dec-2021

Correspondence Address:
Omar Mohammed Al-Saeed
College of Medicine, Taif University, Taif 21944
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/sjhs.sjhs_163_21

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  Abstract 


Recent reports found that the prevalence of multiple sclerosis (MS) in Saudi Arabia shows an increasing pattern but still less than that recorded in the West. The article will discuss the prevalence, pathology, risk factors, diagnostic modalities, and treatment of MS in Saudi Arabia. In this review, we searched PubMed/Medline database, and all studies that reported the prevalence, pathological and clinical types, diagnostic criteria, diagnostic modalities, and methods of treatment of MS in Saudi Arabia were included. the risk factors included consanguinity, Vitamin D deficiency, viral infection, and change in lifestyle. The presentation is similar to that recorded in western reports, but the course is different. KSA neurologists use the McDonald 2010 criteria for diagnosing MS. In the Kingdom, treatment of MS involves several disease-modifying drugs and these drugs are given according to the clinical course and form of the disease.

Keywords: Management, multiple sclerosis, prevalence, Saudi Arabia


How to cite this article:
Al-Saeed OM, Albogami MF, Hatem M. Multiple Sclerosis in Saudi Arabia: A literature Review. Saudi J Health Sci 2021;10:160-4

How to cite this URL:
Al-Saeed OM, Albogami MF, Hatem M. Multiple Sclerosis in Saudi Arabia: A literature Review. Saudi J Health Sci [serial online] 2021 [cited 2022 Jan 24];10:160-4. Available from: https://www.saudijhealthsci.org/text.asp?2021/10/3/160/331773




  Introduction Top


Different risk factors may be involved as consanguinity, Vitamin D deficiency, viral infection, and change in lifestyle. The pattern of presentation (blurred vision, weakness, tingling sensations, unsteadiness, and fatigue) is similar to that recorded in western reports, but the course is different where relapsing-remitting course is the most common in Saudi Arabia followed by progressive relapsing and primary progressive disease. KSA neurologists use the McDonald 2010 criteria for diagnosing MS and they consider magnetic resonance imaging (MRI) as the best imaging technology for detecting the presence of MS plaques or lesions in different parts of the central nervous system (CNS). In the Kingdom, treatment of MS involves several disease-modifying drugs that decrease the rate of the relapse and minimize the severity of the relapse and neurological disability and these drugs are given according to the clinical course and form of the disease. This article will discuss the prevalence, pathology, risk factors, diagnostic modalities, and treatment of MS in Saudi Arabia.


  Methods Top


Data were extracted from the Medline/PubMed database. We searched for articles published from 1988 to 2021, using the keywords: multiple sclerosis (MS), Saudi Arabia, prevalence, and management. We selected all original hospital-based and community-based studies that fitted our search criteria. The outcome of the search included prevalence, pathological and clinical types, diagnostic criteria, diagnostic modalities, and methods of treatment. All data were gathered, analyzed, tabulated, and compared. All data were discussed to fulfill the article outcome.


  Etiology and Risk Factors Top


MS is the most common autoimmune disease that affects the CNS.[1],[2] Genetic predisposition is usually found in addition to other factors as; Vitamin D deficiency, smoking, viral infection, and childhood obesity.[1],[2],[3],[4],[5],[6] According to Kurtzke classification, Saudi Arabia is considered as one of the low risk countries; however, recent reports have been found that MS may be underdiagnosed the Kingdom with actual increase in incidence.[2]

Al Wutayd et al.,[7] in their review, found that certain viral infections as measles in late childhood and consuming fast food are associated with high risk for MS, while the consumption of fruits and coffee and exposure to are correlated with lower incidence of the disease in the KSA and other Gulf countries. Recent studies found a higher incidence of MS among those with Vitamin D deficiency (28%–80% of adult Saudis have deficiency).[7],[8] Consanguinity may play an important role in increasing the risk of MS in the KSA, according to the study of Al Jumah et al.[9] who recommended further studies of the role of this prevalent problem.

In MS whatever the etiology a cascade of autoimmune degenerative processes occur where autoreactive B cells cross the blood–brain barrier and infiltrate the CNS forming ectopic lymphoid follicles with activation of microglia.[2] Antigen/antibody reactions with cytokine production are also involved leading to inflammation, demyelination, axon loss, and fibrosis.[1],[2]

The study of the prevalence of MS in the KSA depends on few epidemiological hospital-based studies [Table 1].[9],[10],[11],[12],[13],[14],[15] Yaqub and Daif[10] reported in their study an increasing incidence of MS in Saudi Arabia and recorded that the site of the lesions and the presentation are similar to that recorded in the West, but the course and disease evolution are different.
Table 1: Baseline characteristics of multiple sclerosis patients in Saudi Arabia

Click here to view


Al-Deeb[13] and Bohlega et al.[14] estimated the prevalence of MS in Saudis to be 30–40/100,000 individuals and the latter emphasized on under-diagnosis of MS in Saudi Arabia and that the incidence of the disease is increasing.

Al Jumah et al.[9] found that the estimated projected prevalence of MS in the KSA was higher for the central region than others and lowest in southern one and reported that the prevalence of MS for all population to be 40.4/100,000 and it was 61.95/100,000 in Saudi nationals.


  Diagnosis Top


MS must be early diagnosed for successful management as permanent axonal loss begins early in the course of the disease, and it was found that the treatment is more effective in the inflammatory stage before massive axonal loss.[16],[17],[18],[19],[20],[21],[22],[23] The identified courses of MS are clinically isolated syndrome (CIS), relapsing-remitting MS (RRMS), primary progressive MS (PPMS), and secondary progressive MS.[19] Daif et al.[12] and Al Jumah et al.[9] recorded in their studies that relapsing-remitting course was found in about 60% of studied patients, and progressive relapsing course was diagnosed in more than 20% of cases, while the primary progressive was reported in <20%. Another study found that over 90% of the patients in the KSA were diagnosed with relapsing-remitting form.[24]

Globally, the disease is more common in females than males which is similar to that recorded in the Saudi studies.[2],[3],[9],[12] Al Daif et al.[12] reported in their study that the mean age at onset in Saudi patients was lower than that of the non-Saudis (25.9 vs. 29.4 years, respectively). The median age of patients at presentation in global reports is around 25 years[2],[3] Al Jumah et al.[9] found a minimal difference in age and sex from that reported in the global reports where the median age of first attack was 27 years and 66.5% being females.

The most common presentations of MS patients are blurred vision, easy fatigability with weakness, paresthesia, and postural instability; however, progressive disability may occur secondary to episodes of optic neuritis or spinal cord syndrome.[19] Al Jumah et al.[9] found that 57.1% of patients in Saudi Arabia presented for the first time by muscle weakness followed by visual and sensory manifestations (48.2% and 47.3% respectively), and in most of the patients, the disability was minimal. Daif et al.[12] reported in their study that the most common presentation of MS in Saudi and non-Saudi patient in the KSA was weakness followed by sensory impairment, which is similar to that in western world.

According to the guidelines of Saudi neurologists:[9],[16],[17],[18],[19],[20],[21],[22],[23],[24],[25]

  • The diagnosis of MS is based on the patient's medical history and the neurologic examination
  • Diagnosis should be made by a neurologist and not by other specialists and is based on the McDonald 2010 criteria
  • After establishing the diagnosis, it is recommend that the patient should be regularly followed up by an expert neurologist, more frequently after the early phase of diagnosis.



  The Criteria Include the Following Top


At least one of the following criteria is required for the diagnosis of MS.[16],[17]

  • Two or more clinical attacks with two or more clinically evident lesions on an objective basis
  • Two or more clinical attacks with one clinically evident lesion on an objective basis and a suggestive clinical history of a previous lesion
  • Two or more clinical attacks with one clinically evident lesion on an objective basis with MRI evidence of space dissemination [Table 2]a
  • CIS (CIS; one evident clinical attack) with two or more clinically evident lesions on objective basis with MRI evidence of time dissemination or presence of oligoclonal bands specific to CSF
  • CIS with one clinically evident lesions on objective basis with MRI evidence of space dissemination with dissemination in time [Table 2]b evident on the MRI or presence of oligoclonal bands specific to CSF.
Table 2: Dissemination in space versus dissemination in time

Click here to view



  Primary Progressive Multiple Sclerosis Top


According to the McDonald criteria, the diagnosis of PPMS requires:

  • One or more year of progressive disability associated with two of the following:


    • One or more periventricular, cortical or juxtacortical, or infratentorial T2-hyperintense lesions.
    • Two or more spinal cord T2-hyperintense lesions.
    • Oligoclonal bands in CSF specific for MS.


To summarize

  • MRI is the best imaging modality to detect MS lesions in different parts of the CNS (done in 98.4% of diagnosed cases in the KSA)[9],[19],[21],[24],[25],[26]
  • In Saudi patients, laboratory examination of cerebrospinal fluid is limited by the invasiveness of lumbar puncture, even though it is done in 37.7% of patients[9],[24],[25],[26]
  • In Saudi Arabia it is recommended to add other tests to rule out other similar disorders which are prevalent in the KSA such as vasculitis, Behcet's disease, brucellosis, and B12 deficiency.[9],[26]



  Treatment Top


Many therapeutic agents are available or still under investigation for treatment of MS, even though none of which proves to be curative.[4],[14] These therapeutic agents are given to modify the course of the disease with decrease in the relapse rate, severity, and neurological disability; however, the values of these drugs are limited in primary progressive form.[4],[26]


  Disease-Modifying Treatments in Relapsing-Remitting Multiple Sclerosis Top


Disease-modifying treatments which have been approved by the U. S. Food and Drug Administration (FDA) and the European Medicines Agency are interferon beta-1a, interferon beta-1b (IFNbeta-1b), glatiramer acetate, mitoxantrone, natalizumab, and fingolimod.[4],[14],[19],[26]

IFNβ is considered by Saudi neurologists as first-line agents which has a long-term benefit with low risk compared with other agents as fingolimod (first-line agent in the USA) and natalizumab, and both drugs are used in the Kingdom as second-line agents in case of treatment failure with IFNβ.[4],[14],[26]

Many authors including MS group of neurologists in Saudi Arabia[19],[26] found that interferon beta-1b is safe and valuable for MS treatment, emphasizing that high dose/high frequency of that agent is recommended in RRMS. However, the patient must be informed and educated by the neurologist for proper counseling and long-term adherence to the treatment.[26]

It is recommended to increase the dose of interferon beta-1b from 250 μg (standard dose) to 500 μg where the reported effect of this dose was superior to other drugs such as natalizumab and fingolimod.[4] Mitoxantrone is of limited use as it may carry the risk of leukemia in addition to its cardiotoxicity.[4],[14],[19]

Recent clinical trials found that some therapeutic agents used for treatment of other diseases can be repurposed in the treatment of MS as simvastatin, Vitamin D, dimethyl fumarate, and fluoxetine.[14],[19],[26]


  Clinically Isolated Syndrome Top


Stys and Tsutsu[26] emphasized on the early treatment of CIS by interferon to delay the progress to clinically definite MS which is in accordance with recommendations of the Saudi neurologist to give IFNbeta-1b therapy for patients who present with CIS.[14] Glatiramer (available in the KSA) can also delay the development of clinically definite disease if administered after a first clinical demyelinating evidence.[14],[19]


  Vitamin D Supplement Top


Recent studies found that the relapse of MS can be reduced by the administration of 25-hydroxy Vitamin D; in addition, the supplementation by this vitamin for CIS patients can delay the progress to clinically definite MS with a reduction in the number of aggressive immune cells in the patient blood.[6],[27]

The Saudi MS neurologists[14] advocated monitoring of 25-hydroxyvitamin D of all MS patients and to with administration of 5,000–8,000 IU of vitamin D/day.


  Primary Progressive Multiple Sclerosis Top


The FDA-approved drugs such as interferons, glatiramer acetate, natalizumab, and mitoxantrone have not been proven useful in treatment of PPMS.[26] A limited benefit was recorded after intermittent intravenous corticosteroid with alternating methotrexate administration.[28] In agreement with various studies, KSA neurologists advocated symptomatic control of any developed problem in PPMS patients such as pain and spasticity in addition to bladder, bowel, and erectile dysfunction, they also emphasized on the patient maintenance of mobility and fitness.[4],[14],[26],[29],[30]


  Assessing Response to Therapy Top


The Saudi neurologists[14] recommended evaluation of treatment response by MRI at 6–12 months intervals where a poor response is defined by the presence of at least two of the following: one or more relapses in the previous year, an active MRI lesions, or/and sustained increase in the Expanded Disability Status Scale (EDSS) by one step (for EDSS ≤5.5) or half a step for EDSS ≥6.0.

In the treatment of nonresponse in RRMS, patients are advised to increase the dose of interferon or to switch from first-line to second-line agents; however, the first option is preferred by the Saudi Arabian MS neurologists before escalation to second-line agents.[14],[19],[26]


  Summary Top


The prevalence of MS in Saudi Arabia shows an increasing pattern but still less than that recorded in the West. Different risk factors may be involved, and relapsing-remitting course is the most common in Saudi Arabia, followed by progressive relapsing and primary progressive disease. KSA neurologists use the McDonald 2010 criteria for diagnosing MS. Treatment of MS involves several disease-modifying drugs approved by FDA and the beta-interferon is considered the first line of treatment.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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  In this article
Abstract
Introduction
Methods
Etiology and Ris...
Diagnosis
The Criteria Inc...
Primary Progress...
Treatment
Disease-Modifyin...
Clinically Isola...
Vitamin D Supplement
Primary Progress...
Assessing Respon...
Summary
References
Article Tables

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