Cell death in multiple sclerosis

Abstract

Multiple sclerosis (MS) is a chronic autoimmune disorder of the central nervous system (CNS) characterized by inflammatory demyelination and progressive neurodegeneration. Although current disease-modifying therapies modulate peripheral autoimmune responses, they are insufficient to fully prevent tissue specific neuroinflammation and long-term neuronal and oligodendrocyte loss. Growing evidence implicates various regulated cell death (RCD) pathways, including apoptosis, necroptosis, pyroptosis, and ferroptosis, not only as downstream consequences of chronic inflammation, but also as active drivers of demyelination, axonal injury, and glial dysfunction in MS. These RCD modalities contribute to MS pathology by disrupting cellular homeostasis and sustaining immune activation through the continuous release of damage-associated molecular patterns (DAMPs), thereby establishing a self-amplifying loop between cell death and inflammation. Furthermore, distinct RCD forms can co-occur within lesions, contributing to the complex cellular landscape of MS. This review summarizes current understanding of RCD mechanisms in MS, focusing on their contributions to neuroinflammation and neurodegeneration across different disease stages. We also discuss recent therapeutic advances targeting RCD, including approved drugs whose efficacy may be partially attributed to modulation of cell death, and emerging small-molecule inhibitors targeting key cell death components such as receptor-interacting protein kinase 1 (RIPK1) and NOD-, leucine-rich repeat-, and pyrin domain-containing protein 3 (NLRP3). Targeting RCD in conjunction with inflammation may represent a more pragmatic approach for mitigating MS progression and neurodegeneration.