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AC- CNS lectures > Module 4.2.2 (Management of Multiple Sclerosis) > Flashcards

Module 4.2.2 (Management of Multiple Sclerosis) Flashcards

1
Q

No preventative therapies in primary and seconday progressive MS. True or False

A

True

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2
Q

What to do in relapsing forms?

A

Introduce immunotherapy early, to slow or minimise disability

AIM: no evidence of disease activity (NEDA), clinically stable, no relapses, no new lesions on MRI

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3
Q

What is used to acute inflammatory clinical events (relapses)?

A

Corticosteroids

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4
Q

What is the focus of MS therapy?

A

Easy symptoms caused by neurological damage (QOL)

Adherence to a healthy lifestyle

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5
Q

When to use immunotherapy in MS? What drugs are used?

A

Indicated for patients with relapsing forms of MS and active disease

> required expert management = risks vs benefits

Monoclonal antibodies (alemtuzumab, natalizumab, ocrelizumab)

  • more potent but higher risk therapies
  • started early in high risk patients

modern approach: use highly effective treatment early, to achieve NEDA (no evidence of disease activity)

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6
Q

What potency are oral immunotherapies such as dimethyl fumarate, fingolimod, teriflunomide, cladribine

A

Moderate potency

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7
Q

Why older drugs like interferon beta and glatiramer not used anymore?

A

Relapses more common than with other drugs

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8
Q

These drugs are rarely used, but when they may be used?

A

Rapidly progressive MS

When patient does not meet criteria for other therapies or C/Is

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9
Q

What are the three monoclonal antibodies used? What are their ADRs?

A
  1. Alemtuzumab

ADR: infusion reactions, thyroid dysfunction, blood dyscriasis, anti-GBM, kidney disease (rare), listeriosis (rare)

  1. Natalizumab

ADR: infusion reactions, hypersensitivity reactions, infection (UTI,RTI), hepatotoxicity, progressive multifocal leukoencephalopathy (PML)

> monitor for PML and for JCV

  1. Ocrelizumab

> License for RRMS (relapse remitting MS) and PPMS (primary progressive MS); only PBS subsidised for RRMS

ADR: hypersensitivity and infusion-related reactions, infection, transient neutropenia

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10
Q

What are the four main oral immunotherapies used? ADRs?

A

1. Dimethyl fumarate

ADR: NVD, flushing, leucopaenia, lymphopaenia, rash, itch, increased ALT/AST, proteinuria, PML

2. Fingolimod

ADR: bradycardia, transient 1st degree AV block, increased LFTs, blood dyscriasis, cough, dyspnoea, infection (e.g. shingles), mascular oedema, oppurtunistic CNS infections, PML

3. Teriflunomide

ADR: N/D, alopecia, rash, infeciton, blood dyscriasis, neuropsychiatric effects, increased ALT/AST - hepatitis, hypersensitivity reactions, SJS, interstitial lung disease

> Washout procedures (activated charcoal or cholysteramine) in cases of toxicity (as for leflunonomide)

4. Cladribine

2 treatment courses, 12 months apart

Safety concerns: severe lymphopenia, infection, possible malignancy

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11
Q

ADR of interferon beta and glatriamer? What is license for?

A

Licensed for 1st demyelinating event suggestive of MS

interferon beta (interferon beta-1a and 1b; also peginterferon beta 1-b = similar efficacy)

ADR: injection site reaction, flu-like symptoms (use at night and use paracetamol to manage before), depression, elevated LFTs, blood dyscriasis, neutralising antibodies (reduced efficacy and loss of effect after 2 years)

glatiramer

ADR: injection site reactions, post-injection reaction, nausea, arthralgia, oedema, hypertonia, tremor, anti-glatiramer Abs

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12
Q

How to manage acute relapses if they are:

A) mild relapses

B) moderate to severe relapses. What medication to use?

A

A)

  • If no signs of disability, reassure and monitor

B)

  • Develop over hours to days
  • Objective neurological signs, consistent progressive sx that can be localised to part of the CNS
  • Corticosteroid therapy hastens recovery and improves short-term clinical outcome –> also prevent neuronal loss and improve longer-term outcomes

> methylprednisolone sodium succinate IV once daily for 3 days

  • oral therapy when IV is unavailble
  • plasma exchange in severe cases
  • review for precipitating factors: fever, URTI, UTI
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13
Q

What are some of the complex symptoms that has to be managed in MS?

A
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14
Q

How to manage spasticity in MS which occurs due to corticospinal tract damage?

A

Management to reduce pain, improve mobility and prevent contractures

  • Baclofen
  • Add BDZ at night to help spasms (clonazepam, diazepam)
  • Gabapentin if neuropathic pain and spasms
  • Medicinal cannabis –> nabiximols, other cannabis products
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15
Q

How to manage reduced mobility in MS?

A

Fampridine MR

  • Improves walking speed; modest effect on cognitive function

ADR: insomnia, anxiety, tremor, constipation, dyspnoea

> renally cleared

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16
Q

What type of pain in MS?

A

Pain

  • often trigeminal neuralgia, neuropathic pain
17
Q

What to do for fatigue in MS? What drugs might help?

A

Common, causes complex and management difficult

  • Seek contributing factors
  • Drugs have poor efficacy; amantadine and modafinil sometimes used
18
Q

What to do for bladder symptoms in MS?

A
  • Urgency (due to detrusor overactivity) most common
  • Mild symptoms: anticholinergic drug
  • Expert treatments: intradetrusor injections of botulinum toxin, sacral neuromodulation; catheter may be required
19
Q

What is most common bowel symptoms in MS?

A

Constipation most common, also faecal urgency and incontinence

20
Q

Why does psychiatric symptoms occur in MS?

A

Depression common, causes:

  • reaction to diagnosis, physical effects and its effects on patient’s life
  • drug of ADR
  • attack of demyelination
21
Q

How to manage sexual difficulties in MS? Why does it occur?

A

Due to spinal plaques, psychological factors, relationship difficulties, fatigue or medication

  • Specialist counselling +/- sildenafil in men (viagra)
22
Q

General health advice for MS?

A
  • Healthy, low fat diet –> improve BMI, lipid profile, possibly fatigue
  • Low serum vitamin D level associated with increase relapse frequency and MRI activity in early MS

> check vitamin D at diagnosis and supplement if < 50 nmol/L

> benefits of higher doses unclear

  • Stop smoking –> increases risk of MS, and disease progression
  • Increased exercise and moderate alcohol intake –> associated with lower disability
  • Screening for HIV, TB (immunotherapy reactivates latent TB), hepatitis B and C required prior to immunotherapy initiation
  • Vaccination –> influenza vaccine safe; live vaccines dangerous with some immunotherapies
23
Q

Discuss general health advice in relation to womens health. What type of MS medication is safest in pregnancy e.g.?

A

Hormonal contraception and HRT safe

  • Risk of MS relapse decreased in pregnancy but increased in 3 months after delivery

> pregnancy should be planned

  • Glatiramer and dimethyl fumarate safest in pregnancy

> immunotherapy can usually be stopped before attempting conception –> restart 2 weeks post-partum

> evidence lacking for safety of breastfeeding during immnotheapy

24
Q

How to monitor for efficacy of treatment in MS?

A
  • Clinical monitoring + MRI (every 3-12 months) –> for lesions
  • Further disease activity requires escalation of therapy or switch to an alternative agent
  • Discontinue therapy in severe diasability or disease progression
  • S and S requiring symptomatic relief
25
Q

How to monitor for safety factors in MS?

A
  • Infection suh as UTI or URTI
  • FBP –> monitor for blood dyscriasis
  • LFT –> >3 times ULN = monitor patient
  • Drug specific toxicities

> U and Es, TFTs (atalizumab), PML (6-monthly JC virus Ab testing for seronegative patients), cardiac (fingolimod), opthalmological

AC- CNS lectures (28 decks)

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