MS Flashcards
Relapsing Remitting MS (RRMS)
-Series of attacks that occur over months-years apart
-causing increase in level of disability
-most common form of MS
Secondary Progressive MS (SPMS)
Starts similar to RRMS but over time the immune attack becomes constant
Primary progressive MS (PPMS)
constant immune attack
Progressive relapsing MS (PRMS)
-constant immune attack + acute attacks superimposed
-most rare form
Charcot’s Neurologic Triad
Dysarthria (difficult/unclear speech)
-plaques in brainstem
Nystagmus (rapid involuntary eye movement)
-plaques in optic nerve
Intention tremor
-plaques in motor pathways in spinal cord
Lhermitte’s sign
Electric shock-like feeling that runs down the back and radiates to limbs when bending neck forward
MS diagnostic criteria
- at least 2 documented clinical exacerbations separated by time and space
- 2 distinct MRI lesions separated by time and space
Clinically Definite MS
2 attacks + 2 lesions
Laboratory Supported MS
- 2 attacks + either clinical or paraclinical evidence of 1 lesion + CSF abnormalities
OR
-1 attack + clinical evidence of 2 lesions + CFSF abnormalities
OR
-Clinical evidence of 1 lesion + paraclinical evidence of another lesion + CSF abnormalities
Clinically Isolated Syndrome
1st MS attack
MS Relapse Treatment
Steroids:
- Methylprednisolone
For pats with poor IV access:
- Corticotropin acthar gel IM or SQ
Progressive Multifocal Leukoencephalopathy (PML)
A sometimes fatal opportunistic infection caused by the activation of latent John Cunningham polyoma virus in immunocompromised patients
- demyelinating disease similar to MS
Interferon Beta-1a
Avonex- IM
Rebif- SQ
Plegridy - SQ
Indication: CIS, RRMS, active SPMS
MOA: suppress T cell proliferation and decreases BBB permeability
ADE: FLU LIKE SX!, injection sight rxn, depression, myalgia, arthralgia, asthenia, malaise, diaphoresis, myasthenia, abdominal pain
Interferon Beta-1B
Betaseron (SQ)
Extavia (SQ)
Indication: CIS, RRMS, active SPMS
MOA: suppress T cell proliferation and decreases BBB permeability
ADE: FLU LIKE SX!, injection sight rxn, depression, myalgia, arthralgia, asthenia, malaise, diaphoresis, myasthenia, abdominal pain
Glatiramer Acetate (Copaxone, Glatopa)
SQ
Indication: CIS, RRMS, active SPMS
MOA: alteration of T cell activation and differentiation
ADE: INJECTION SITE RXN, transient flushing, vasodilation, chest pain, tightness, asthenia, N/V, pain, arthralgia, anxiety, palpitations, dyspnea, constriction of throat
Natalizumab (Tysabri)
IV
Indication: CIS, RRMS, active SPMS
MOA: prevents leukocyte adhesion, prevents transmigration of leukocytes across the endothelium into inflamed parenchymal tissue
ADE: PML, infusion rxn, respiratory tract infection, UTI, depression, HA, fatigue, diarrhea, cholelithiasis, arthralgia
Alemtuzumab (Lemtrada)
IV
Indication: RRMS, SPMS (generally reserved for inadequate response to 2 or more meds)
MOA: target CD52 on immune cells causing long term reduction in T cells
ADE: AUTOIMMUNE THYROID DISORDERS, rash, HA, pyrexia, fatigue, pruritis, N/V/D, dizziness, chills, insomnia, chest discomfort, dyspnea, musculoskeletal pain, flushing, infections
Pearls: premedicate with corticosteroids (methylpred) + use antiviral prophylaxis from 1st day of treatment -> 2 months post treatment
Monitor: CBC, urinalysis, TSH, PML, HPV, skin screen
Ocrelizumab (Ocrevus)
IV
Indication: PPMS!!!!, CIS, RRMS, SPMS
MOA: Binds CD20 on B cells -> depletes them from circulation
ADE: infusion rxns, UTI, URTI, HA, nausea, infection, malignancy, PML
CI: active HBV infection
Ofatunumab (Kespimpta)
SQ
Indication: CIS, RRMS, SPMS
MOA: binds specifically the extracellular loops of the CD20 molecule -> depletes B cells from circulation
ADE: infection, injection rxn, PML, CI in pregnancy, back pain
Mitoxantrone (Novantrone)
IV
Indication: PRMS!!!! SPMS, worsening RRMS
MOA: intercalates with DNA strands causing breaks and inhibits DNA repair through topoisomerase II
ADE: Cardiotoxicity, bone marrow suppression, stomatitis, esophagitis, oral ulceration, N/V, alopecia, HA, fatigue, hepatic dysfunction
Mavenclad (cladribine)
PO
Indication: RRMS, active SPMS
- NOT CIS
MOA: prodrug -> incorporates into DNA -> breakage + shutdown of DNA repair -> depletion of lymphocytes
ADE: Malignancy, teratogenicity, bone marrow suppression, infection, PML, hepatotoxicity, cardiotoxicity, HA, Nausea, fever, insomnia, HTN, alopecia
Monitor: CBC, infection status, VZV antibody status, pregnancy, LFT, MRI, cancer screening
Mavenclad (cladribine) dosing
3.5 mg/kg over 2 years.
Administered as 1.75 mg/kg each year
- in 2 4-5 day cycles
- start second day cycle 23-27 days after the last dose of the second cycle
- start 2nd year treatment course >/= 43 weeks after last dose
Fingolimod (Gilenya)
PO
Indication: CIS, RRMS, + SPMS in pats >/=10
MOA: acts on Sphingosine 1 phosphate -> depletes T lymphocytes in blood stream, inhibits lymphocyte release from lymphatic organs
ADE: bradycardia, QTc prolongation, HA, lymphopenia, leukopenia, infection, macular edema, inc BP, HTN, inc LFTs, abdominal pain, back pain, diarrhea
CI: pats w/ heart conditions
Monitoring: ECG, monitor for bradycardia 6 hrs pos 1st dose
Mayzent / Siponimod
PO
Indication: CIS, RRMS, active SPMS
MOA: acts on Sphingosine 1 phosphate -> depletes T lymphocytes in blood stream, inhibits lymphocyte release from lymphatic organs
ADE: infection, PML, macular edema, bradycardia, AV block, QT prolongation, CVD, reduced forced expiratory volume, inc LFTs, HTN, neurotoxicity, malignancy, discontinuation syndrome, HA, macular edema
CI in CYP2C9 3/3
Monitor: CBC, LFT, ECG, ophthalmologic exam, respiratory function (FEV), VZV antibodies, blood pressure, 1st dose monitoring for pats with sinus bradycardia (HR < 55), AV block, Hx of MI or HF
Mayzent / Siponimod dosing:
CYP2C9 1/1, 1/2, 2/2
0.25mg QD -> titrate -> 2mg QD
Mayzent / Siponimod dosing:
CYP2CP 1/3, 2/3
0.25mg QD -> titrate -> 1mg QD
Zeposia / Ozonimod
PO
Indication: CIS, RRMS, active SPMS
MOA: acts on Sphingosine 1 phosphate -> depletes T lymphocytes in blood stream, inhibits lymphocyte release from lymphatic organs
ADE: similar to IFN B1A, infection , HTN, orthostatic HTN, upper abdominal pain, lymphocytopenia, inc ULN, back pain, macular edema
Monitor: CBC, baseline bilirubin + LFTs, ECG, ophthalmologic exam, less need for 1st dose monitoring
Teflunomide (Aubagio)
PO
Indication: RRMS, SPMS
MOA: blocks pyrimidine synthesis in rapidly dividing cells -> selectively produces a cytostatic effect on proliferating T and B lymphocytes in the periphery
ADE: HA, infections, alopecia, sensory disturbances, nausea, paresthesias, insomnia, inc LFTs, back pain, diarrhea, arthralgia
Monitor: CBC, LFT, screen for latent TB
BBW: hepatotoxicity, teratogenicity
Dimethyl fumarate (Tecfidera)
PO
Indication: CIS, RRMS, active SPMS
MOA: induces T-helper 2- like cytokines -> apoptosis of activated T cells and down regulation of intracellular adhesion molecules
ADE: GI SX, flushing, inc LFTs, transient eosinophilia, lymphopenia, PML
Diroximel Fumarate (Vulmerity)
PO
Indication: CIS, RRMS, active SPMS
MOA: induces T-helper 2- like cytokines -> apoptosis of activated T cells and down regulation of intracellular adhesion molecules
ADE: GI SX, flushing, inc LFTs, transient eosinophilia, lymphopenia, PML
Pearl: high fat meals may significantly decrease max concentration
Monomethyl Fumarate (Bafiertam)
PO
Indication: CIS, RRMS, active SPMS
MOA: induces T-helper 2- like cytokines -> apoptosis of activated T cells and down regulation of intracellular adhesion molecules
ADE: GI SX, flushing, inc LFTs, transient eosinophilia, lymphopenia, PML
Treatment for Spasticity in MS
- Baclofen
- Dantrolene
- Diazepam, clonazepam
- Tizanidine
- Gabapentin, tiagabine, pregabalin
- Botox
- Dalfampridine
Treatment for bladder symptoms in MS (overactive bladder / retention)
- Propantheline
- Oxybutynin
- Dicyclomine/Bentyl
- DDAVP
- catheterization
- imipramine / amitriptyline
- prazosin
- botox
- solifenacin/ vesicare
- darifenacin/ enablex
- trospium
- hyoscyamine
- fesoterodine / toviaz
- mirabegron (Myrbetiq)
Treatment for sensory symptoms of MS (Paresthesias, neuropathic pain)
- carbamazepine, oxcarbazepine
- phenytoin
- TCAs
- Gabapentin
- lamotrigine
- pregabalin
- duloxetine
Treatment for Fatigue/ Cognitive / Emotional issues in MS
- Amantadine
- SSRI / SNRI
- Modafanil
- Methylphenidate
- Dextroamphetamine
Pseudobulbar Affect
- uncontrollable episodes of crying or laughing
- treatment with Nuedexta (Dextromethorphan + Quinidine)
Improved walking with MS:
Dalfampridine (Ampyra)
- broad spectrum CCB
Use of Cannabinoids in MS treatment
effective for spasticity, pain, painful spasm, and bladder voiding
