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PHRM 845 > (3.4) Pharmacotherapy of MS > Flashcards

(3.4) Pharmacotherapy of MS Flashcards

1
Q

What is dissemination in time (DIT)?

A
  • Time between evidence of new lesions in subsequent MRIs (30 days)
  • Damage that has happened more than once
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2
Q

What is dissemination in space (DIS)?

A
  • Need for >1 T2 lesions appearing in at least 2 of 4 MS typical CNS regions (cortical, periventricular, infratentorial, spinal cord)
  • Damage that is in more than once place
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3
Q

What is clinically isolated syndrome (CIS)?

A
  • Descriptor of a first demyelinating event involving the optic nerve, cerebrum, cerebellum, brainstem, or spinal cord
  • Most will develop MS within 20 years
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4
Q

What is relapsing remitting MS (RRMS)?

A

Consists of relapses w partial or complete remission between relapses
- Most will become progressive type over time

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5
Q

What % of diagnoses is RRMS?

A

80-90%

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6
Q

What is secondary progressive MS (SPMS)?

A

About 80% of RRMS pts will progress to SPMS, consisting of fewer relapses w continuing disability

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7
Q

What is primary progressive MS (PPMS)?

A

Progressive form from onset w minor improvements or periods of stability

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8
Q

What % of pts have PPMS?

A

10-15%

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9
Q

How common is PPMS?

A

More common in pts diagnosed in later years (>50 years of age)

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10
Q

What is progressive relapsing MS (PRMS)?

A

Steadily worsening disease from onset w later, clear, acute relapses

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11
Q

Is there recovery and remission from PRMS?

A

May be some recovery from acute attacks, but no remission between relapses

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12
Q

How common is PRMS?

A

PRMS is the least common form (about 5% of diagnoses)

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13
Q

What is the first line tx of acute attacks?

A

High dose corticosteroid tx; oral or IV based on inpt or outpt setting

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14
Q

What is the inpatient setting corticosteroid given for tx of acute attacks?

A

Methylprednisolone 500-1000mg IV daily for 3-7 days, w or without an oral taper over 1-3 weeks

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15
Q

What is the outpatient setting corticosteroid given for tx of acute attacks?

A

Oral prednisone 1250mg every other day x5 doses w/o need for taper

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16
Q

What is another option for tx of acute attacks?

A

Adrenocorticotropic hormone (H.P. Achtar) or plasma exchange

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17
Q

Patients w optic neuritis should receive what acute attacks tx?

A

IV methylprednisolone

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18
Q

What causes progressive multifocal leukoencephalopathy (PML)?

A

Reactivation of dormant John Cunningham Virus (JCV)

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19
Q

MS patients must be tested for what and why?

A

Patients must be tested for JCV antibodies to check for PML

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20
Q

What type of vaccines are preferred for pts w MS?

A

Inactivated vaccines

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21
Q

Which type of vaccines are not recommended in MS pts and why?

A

Live, attenuated vaccines are not recommended bc the ability to cause the disease is weakened, but not eliminated

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22
Q

What MS medication do you NEVER use together w live virus vaccines?

A

Alemtuzumab

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23
Q

Which vaccine should be considered by MS pts who have never had chicken pox?

A

Varicella vaccines, especially if they may start a MS medication that suppresses cell-mediated immunity (like fingolimod, alemtuzumab)

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24
Q

What are important counseling tips of dimethyl fumarate, diroximel fumarate, and monomethyl fumarate’s dosage form?

A
  • The capsule SHOULD NOT be opened and sprinkled on food
  • Do not chew or crush
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25
What should be monitored when using dimethyl fumarate, diroximel fumarate, and monomethyl fumarate?
- Monitor LFTs (Hepatotoxicity) - Monitor CBC w differential (neutropenia)
26
What is associated with dimethyl fumarate, diroximel fumarate, and monomethyl fumarate?
Associated w PML
27
What is a common SE of dimethyl fumarate, diroximel fumarate, and monomethyl fumarate and how can it be relieved?
- Can cause flushing - May take aspirin 30 minutes prior to dose to reduce risk of it happening
28
What medications are in the sphingosine-1-phosphate receptor modulators?
Fingolimod, ozanimod, ponesimod, siponimod
29
A pt has failed to tolerate a S1P receptor modulator. Can they take a different one?
No, DO NOT switch between S1P receptor modulators
30
What are CIs w S1P receptor modulators?
- Past arrhythmia diagnosis - Any of the following CV diagnoses in the past 6 months: MI, unstable angina, stroke/TIA, class 3/4 HF
31
What are the monitoring parameters of S1P receptor modulators?
- Monitor CBC bc of increased risk of infection - Pts should have routine eye exams bc of macular edema
32
What happens when a S1P receptor modulator is discontinued?
D/c can result in significant worsening of MS sxs
33
Why must pts who’ve taken their 1st dose of S1P receptor modulators be monitored for 6 hours?
Bradycardia may occur - do an ECG at baseline and end of observation period
34
Which S1P receptor modulator should not be used w an MAOi?
Ozanimod
35
What is required for siponimod before prescribing?
CYP2C9 genotype testing required before prescribing
36
What are SEs of glatiramer acetate?
- Injection SEs immediately post injection - Flushing, sweating, dyspnea, chest pain, anxiety, itching
37
What is a counseling tip that must be done w glatiramer acetate and why?
Pts MUST rotate injection sites bc likely permanent lipoatrophy may occur
38
Pt reports chest pain after using glatiramer acetate. Is this clinically significant?
Not usually clinically significant, unless pt has PMH of CV risk
39
Can glatiramer acetate be used during pregnancy?
- May be preferred if tx is necessary in pregnancy - Teratogenic effects are unknown
40
What is a common SE of interferons and how can this risk be reduced?
- Flu-like sxs can occur after injection - Decrease risk by pre-treating w acetaminophen or NSAID, dosing in evening/at bedtime and gradual dose titration
41
What are psychiatric SEs of interferons?
Depression, suicidal thinking
42
What are monitoring parameters w interferons?
Monitor LFTs and TSH - elevated liver function tests and thyroid dysfunction
43
What drugs are in the monoclonal antibodies class for tx of MS?
Alemtuzumab, Natalizumab, Ocrelizumab
44
What are possible severe AEs of alemtuzumab?
Possible fatal infusion rxns and autoimmune conditions
45
What is alemtuzumab associated w?
Associated w increased risk of malignancies
46
What is CI in alemtuzumab?
CI in pts w HIV infection bc of prolonged decreased CD4 count
47
What is Natalizumab associated w?
Significant association w PML
48
What differentiates ocrelizumab from the other monoclonal antibodies?
Ocrelizumab is the only drug FDA-approved for PPMS
49
What is CI w ocrelizumab?
CI in active hepatitis B
50
What is ocrelizumab associated w?
Associated w increased risk of malignancies
51
What should be completed before starting monoclonal antibody tx?
Complete vaccinations at least 6 weeks before
52
What can be used to premedicate before starting monoclonal antibody dose?
Steroid, antihistamine, acetaminophen
53
Use of teriflunomide in pregnancy.
CONTRAINDICATED - For accelerated elimination, cholestyramine or activated charcoal for 11 days
54
Use of mitoxantrone in pregnancy.
Contraceptive required for tx, pregnancy test before each infusion
55
Use of fingolimod in pregnancy.
Contraception during tx and for at least 2 months after d/c
56
Use of ozanimod in pregnancy.
Contraception during tx and for at least 3 months after d/c
57
Use of ponesimod in pregnancy.
Contraception during tx and for at least 7 days after d/c
58
Use of siponimod in pregnancy.
Contraceptive during tx and for least 10 days after d/c
59
Use of ocrelizumab in pregnancy.
Contraceptive during tx and for at least 6 months after d/c
60
Use of caldribine in pregnancy.
- Contraceptive required + barrier method for at least 6 months after d/c - CI in breastfeeding
61
What happens to the relapses of MS during pregnancy and after pregnancy?
Rates of relapses of MS decreases during pregnancy, increases for first 3 months post-partum, then returns to pre-pregnancy rate
62
What is the pseudobulbar affect?
Frequent and inappropriate episodes of crying, laughing, or both, unrelated to actual mood
63
What is the cause of pseudobulbar affect?
- Cause unknown - May be related to disruption of neural pathways from brainstem to cerebellum
64
What is used to tx pseudobulbar affect?
Neudexta (dextromethorphan/quinidine)
65
What is the MOA of dextromethorphan in Neudexta?
Agonist at sigma-1 receptors
66
What is the MOA of quinidine in Neudexta?
A P450 2D6 inhibitor that blocks the conversion of dextromethorphan to dextrorphan, allowing dextromethorphan to reach CNS
67
What lifestyle modifications help w gait abnormalities/walking speed?
Physical training, gait training, exercise
68
What drug therapy treats gait abnormalities/walking speed?
Dalfampridine (Ampyra)
69
What is the MOA of dalfampridine?
Blocks K channels and prevents repolarization of cell, which prolongs action potentials and nerve impulse transmission in demyelinated area, which may improve walking speed
70
Which formulation of dalfampridine is preferred?
ER
71
What are possible SEs of dalfampridine ER?
UTIs, insomnia, dizziness, headache, nausea
72
Why is the dalfampridine ER formulation preferred over the IR?
IR dosage form and dose escalation is associated w seizures; IR dosage form CI in pts w hx of seizures

PHRM 845 (48 decks)

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