5. Influence of the treatment of multiple sclerosis in sleep

The therapeutic approach to multiple sclerosis involves pharmacological, rehabilitative, psychological, lifestyle modifying interventions, etc. These can be used independently or coordinated with each other with a holistic view. This approach involves changes in the structure of sleep, which are not always beneficial.

#### 5.1. Treatment of relapses

Therapeutic options to treat MS relapses include oral glucocorticosteroids [70, 71] or their intravenous administration at a high dose as first line and therapeutic plasma exchange (TPE) and intravenous immunoglobulin (IVIG) as second line treatments in glucocorticosteroids unresponsive patients [72], corticotrophin injection and Acthar [73].

The action mechanisms of glucocorticosteroids in the immune system are pleiotropic, induced apoptosis of peripheral blood leucocytes and down-regulation of T-cell activity delayed for 7–10 days after a 5-day course of administration [72].

6. Conclusions

Conflict of interest

concerning the manuscript.

Author details

Spain

References

Sleep disorders in patients with MS are frequently underdiagnosed. Clinicians caring for

Sleep Disorders in Multiple Sclerosis http://dx.doi.org/10.5772/intechopen.72831 187

All the symptoms are related, many of them share the same pathophysiology where it is not possible to identify the precipitating factor and the perpetuating factor. Sleep disturbances increase the risk of mortality, co-morbidities (cardiac disease, obesity and diabetes) and can contribute to the depression, pain, cognitive impairment and fatigue symptoms which are

The therapeutic approach to sleep disorders in MS involves pharmacological, rehabilitative, physical, psychological, educational and lifestyle modification interventions. These can be

The list of drugs being taken by the patient should always be reviewed and doses should be

Montserrat González Platas and María Yaiza Perez Martín report no conflicts of interest

Neurology Service, Hospital Universitario de Canarias, La Laguna, Santa Cruz de Tenerife,

[1] Ma S, Rui X, Qi P, Liu G, Yang J. Sleep disorders in patients with multiple sclerosis in

[2] Tachibana N, Howard RS, Hirsch NP, Miller DH, Moseley IF, Fish D. Sleep problems in

[3] Merlino G, Fratticci L, Lenchig C, Valente M, Cargnelutti D, Picello M, et al. Prevalence of "poor sleep" among patients with multiple sclerosis: An independent predictor of mental

used independently in combination, with combined therapies being more effective.

adjusted or suspended if necessary to avoid interference with sleeps disorders.

patients with MS should routinely screen for sleep disturbances.

disabling and worsen the prognosis of multiple sclerosis.

Montserrat González Platas\* and María Yaiza Pérez Martin

China. Sleep Breath. 2017;21(1):149-154

\*Address all correspondence to: montserrat.gonzalezplatas@gmail.com

multiple sclerosis. European Neurology. 1994;34(6):320-323

and physical status. Sleep Medicine. Jan 2009;10(1):26-34

TPE is the removal of circulating antibodies, cytokines, immune complexes and complementary factors, all of which are assumed to be involved in immune-mediated neuroinflammation.

IVIG reduces or prevents the activation of inflammatory cells and alters antibody responses.

Optimal treatment of relapses increases the chance of limiting or avoiding residual deficits which have been related to the progression of disability in MS [72].

Sleep disturbance (insomnia) might be one of the side effects of corticosteroid therapy during an acute exacerbation in MS. Benzodiazepines are useful during these periods [74].

#### 5.2. Disease-modifying therapies

Interferons are DMTs that produce major alterations of sleep, mainly by the flulike reaction, fever, headache, alteration of the mood and fatigue. It is imperative to treat these effects to improve the patient's quality of life including finding what time is best to administer the treatment. The monoclonal antibody Natalizumab could reduce fatigue [37].

#### 5.3. Symptomatic treatment

Specific treatment of symptoms of MS manifestations occasionally interferes with sleep quality, leading to insomnia or drowsiness. The treatments the patient is receiving need to be reviewed in the event of any sleep disturbance.

Selective serotonin reuptake inhibitors, while helpful for depressive symptoms, may worsen insomnia. Stimulants and wake-promoting agents, which are commonly used for fatigue, may interfere with sleep initiation if taken during the late afternoon or early evening hours. Antihistamines, which are used as sleep aids by up to 25% of patients with MS, have the potential to worsen RLS, and thereby worsen sleep-onset insomnia.

Patients suffering from fatigue symptoms are often treated with antidepressants due to the strong association between depression and fatigue. Modafinil, amantadine and aminopyridine are known as fatigue treatment options, although the physician must monitor the real effect on sleep and adjust the administration schedules so as not to mask the effect on fatigue.

Medications used to alleviate MS-related symptoms, including over-the-counter medications, also have the potential to interfere with sleep. Given the high frequency use of these medications in this population, the physician should carefully consider screening for these medications and assessing possible effects on sleep.

#### 5.3.1. Management

The first approach includes reviewing the list of drugs being taken by the patient and adjusting doses or suspending them if necessary to avoid interference with other situations of the patient. In this respect, the multidisciplinary approach to the patient is important.
