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Index arrow Roztroušená skleróza arrow Novinky v léčbě

Novinky v léčbě
Novinky v léčbě Tisk E-mail
Úterý, 15 květen 2007

Jak už bylo mnohokrát řečeno, léčba RS se musí odvíjet od doposud známých mechanismů, které se při rozvoji RS uplatňují. Optimálně by tedy měla pokrýt dva základní mechanismy, které jsou ve hře, a to zánět a degeneraci nervových vláken. 
1) Zánět: Dlouho je známo, že se RS vyznačuje tvorbou zánětlivých ložisek v centrálním nervovém systému (CNS). Tento zánět je autoimunitní, to znamená, že vzniká patologickou reakcí imunitního systému, který rozpoznává některé vlastní struktury CNS jako tělu cizí a zahajuje proti nim útok – zánět. V zánětlivém ložisku se nakupí buňky imunitního systému, dochází k místnímu otoku tkáně vzhledem k větší propustnosti cév v místě zánětu, a výsledkem je poničení obalů nervových vláken. Tyto obaly (myelin) jsou vlastně výběžky podpůrných buněk CNS, které se jmenují oligodendrocyty. Myelin se během vývoje nervového systému vytváří tak, že buňky oligodendrocyty svými výběžky obtáčejí vždy několik nervových vláken. Délka jednoho zatočeného výběžku („buřtíku“) na jednom nervovém vláknu je asi 1–2 mm. Myelin slouží důležitým nervovým vláknům k tomu, aby byla schopna vést nervové impulsy velmi rychle. Pokud se však na určitém úseku nervového vlákna vlivem zánětu myelin rozpadne, dojde k přerušení vedení nervového vzruchu. To znamená klinický příznak a problém, který pacienta přivede k lékaři (porucha zraku při poruše vedení ve zrakovém nervu, porucha hybnosti při poruše vedení v nervových vláknech hybné dráhy, apod.). Pokud není poškozeno vlastní nervové vlákno, vedení nervového vzruchu se po několika dnech obnoví, protože nervové vlákno je schopno fungovat i bez myelinu, jen rychlost vzruchu se zpomalí. Funkce je tedy obnovena. Během několika měsíců se za příznivých okolností může obnovit i myelin, pokud v zánětlivém ložisku zůstaly nepříliš poškozené oligodendrocyty. 
2) Neurodegenerace: V zánětlivém ložisku však nedochází bohužel jen k poškození myelinu. V různé míře (velmi individuálně) dochází i k poškození (zpřetrhání) nervových vláken zbavených ochranného myelinového obalu, a to je jev podstatně závažnější než sama ztráta myelinu (demyelinizace). Ztráta nervových vláken je totiž v CNS jevem nevratným a rozhoduje o ztrátě funkce, která je těmito vlákny zajišťovaná. Je-li tedy např. zničeno velké množství vláken nutných pro pohyblivost pravé ruky, její funkce se už nemůže plně obnovit. Naštěstí máme všichni určité rezervy. Ty se odhadují na přibližně 30-40 % nervového systému. Pakliže přijdeme o tyto rezervy, choroba dále ukrajuje z funkčně nezbytného nervového systému a obnovení funkce vázne. 
Léčba RS by tedy v ideálním případě měla být schopna utlumit zánět, dovolit obnovení myelinu a zabránit ztrátě nervových vláken. Hrozba ztráty nervových vláken vedla k zásadní změně přístupu k léčbě RS v celém světě. Heslem se stalo „time is axon“ (čas je nervové vlákno) a léčebná snaha se přesunula do časných stadií RS, optimálně již po první atace podezřelé z dalšího rozvoje RS (tzv. klinicky izolovaný syndrom – CIS). 
Jaké jsou reálné možnosti léčby? Které léky mají alespoň některé z těchto vlastností? 
Léčbu RS je možno pro přehlednost rozdělit do několika skupin podle stadia choroby: 
1. Léčba akutní ataky (relapsu) nemoci. 
2. Léčba dlouhodobá ve stadiu remitentním, kdy se střídají ataky a remise (úprava příznaků).
3. Léčba ve stadiu sekundární chronické progrese. 
4. Léčba primárně progresivního typu nemoci. 
5. Léčba maligního průběhu nemoci 
6. Léčba symptomů (příznaků) nemoci v kterémkoli stadiu RS

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