Lecture 40-41 OTT

Question 1

2017 MCDONALD DIAGNOSTIC CRITERIA

Answer 1

Dissemination in Time (DIT): Time between evidence of new lesions in subsequent MRISs (30 days) damage that has happened more than once

Dissemination in Space (DIS): Need for > 1T2 lesion appearing in at least two of four MS-typical CNS regions-damage that is more than one place

Question 2

Clinically Isolated Syndrome (CIS)

Answer 2

descriptor of a first demyelinating event involving the optic nerve, cerebrum, cerebellum, brainstem or spinal cord

most will develop MS within 20 years

Question 3

Relapsing Remitting MS

Answer 3

most common type (80-90%)

consists of relapses with partial or complete remission between relapses; most will become progressive type over time

Question 4

Secondary Progressive MS

Answer 4

about 80% of RRMS patients will progress to SPMS, consisting of fewer relapses with continuing disability

Question 5

Primary Progressive MS

Answer 5

10-15% of patients progressive form from onset with minor improvements or periods of stability; more common in patients diagnosed in later years (>50 years)

Question 6

Progressive relapsing MS

Answer 6

least common form

steadily worsening disease from onset with later, clear, acute relapses; may be some recovery from acute attacks, but no remission between relapses

Question 7

Treatment of acute attacks

Answer 7

High-dose corticosteroid is the first choice; oral or IV based on setting

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

If outpatient: oral prednisone 1250 mg every other days x 5 doses without need for taper

Question 8

Adherence to treatment

Answer 8

secondary-progressive MS; female sex; depression; inconvenience; younger age

Question 9

Oral Meds

Answer 9

Dimethyl fumarate (Tecfidera)

Diroximel fumarate (Vumerity)

Fingolimod (Gilenya, Tascenso ODT)

Ozanimod (Zeposia)

Ponesimod (Ponvory)

Siponimod (Mayzent)

Teriflunomide (Aubagio)

Question 10

Injectable Meds

Answer 10

Interferon beta 1a (Avonex, Rebif)

Peginterferon beta 1a (Plegridy)

Interferon beta-1b (Betaseron, Exatvia)

Glatiramer acetate (Copazone)

Question 11

Infusion Meds

Answer 11

Alemtuzumab (Lemtrada)

Natalizumab (Tysabri)

Ocrelizumab (Ocrevus)

Question 12

PML

Answer 12

PATIENTS MUST BE TESTED BY GETTING A MEDICATION BEFORE MS

Question 13

Vaccines

Answer 13

Inactivated vaccines are preferred for people with MS

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

ALEMTUZUMAB-NO LIVE VIRUS VACCINES

Question 14

Dimethyl Fumarate, Diroximel Fumarate, Monomethyl fumarate

Answer 14

Capsule SHOULD NOT be opened and sprinkled on food; do not chew or crush

Monitor LFTs (hepatotoxicity) and CBC with differential (neutropenia)

Associated with PML

Can cause flushing, may take aspirin 30 minutes prior to dose

Question 15

Fingolimod, ozanimod, ponesimod, siponimod

Answer 15

S1P receptor modulators

If a patient fails one should not be switched to another

Contraindicated with past arrhythmia diagnosis

D/C can result in significant worsening of symptoms

Ozanimod: avoid use with MAO inhibitor

Siponimod: CYP2C9 testing is required before prescribing

Question 16

Glatiramer Acetate

Answer 16

Injection side effects: flushing, sweating, dyspnea, chest pain, anxiety

Lipoatrophy may occur at injection site and is permanent: MUST ROTATE

Chest pain may occur outside of injection, usually not clinically significant

May be preferred if treatment is necessary in pregnancy

Question 17

Interferons

Answer 17

Can be dosed SubQ or IM every other day to every 2 weeks depending on the dosage form

Flu-like symptoms can occur after injection–decrease by pre-treating with tylenol or an NSAID, dosing in the evening/ at bedtime and gradual dose titration

Psychiatric side effects: depression, suicidal thoughts

Elevated liver function tests and thyroid dysfunction–monitor LFTs and TSH

Question 18

Alemtuzumab

Answer 18

REMS Program

Possible fatal infusion reactions given in clinic

Associated with increased risk of malignancies

CI in HIV infection–prolonged decrease CD4 count

Question 19

Natalizumab

Answer 19

REMS

Significant association with PML

Not 1st line

Question 20

Ocrelizumab

Answer 20

Only drug FDA approved for PPMS

CI in active hepatitis B

Associated with increase risk of malignancies

Question 21

Monoclonal antibodies

Answer 21

COMPLETE VACCINATION AT LEAST 6 WEEKS BEFORE STARTING TX

Question 22

Teriflunomide

Answer 22

ABSOLUTE CONTRAINDICATION IN PREGNANCY

Question 23

Dalfampridine

Answer 23

blocks K channels and prevents repolarization of the cell, which prolongs action potentials and nerve impulses transmission in the demyelinated axon which may improve walking speed

Question 24

IR dosage form in gait abnormalities and walking speed

Answer 24

IR dosage form and dose escalation associated with seizures, CI in pt with hx of seizures

ER IS PREFERRED

Question 25

Medical Marijuana in MS

Answer 25

Spasticity: OCE/THC decrease pt reported scores

Central pain, painful spasms