MS Flashcards
MS diagnostic score
McDonald Criteria (2017)
Key features required for diagnosis of MS
Dissemination in space and dissemination in time
Differentials for MS
Inflammatory: ADEM, Behcets, NMOSD, MOG, SLE, Vasculitis
Infectious: HIV, Lyme, Neurosyphilis, PML, TB
Genetic: ALD
Granulomatous disease: sarcoidosis, GPA
Vascular: antiphospholipid disease, chronic small vessel ischaemia, migraine
Neoplastic: lymphoma, glioma, GBM, metastases
Neuromyelitis optica spectrum disorder
Immune mediated disease causing demyelination and axonal damage
- prediliction for optic nerve and spinal cord
- most have Ab to aquaporin 4
- causes loss of oligodendrocyte then axonal loss
- NMOSD often long segments of spinal cord
NMOSD diagnostic criteria
Need one of the following:
1. optic neuritis
2. acute myelitis
3. area postrema syndrome (intractable hiccups, nausea / vomiting)
4. Acute brainstem syndrome
5. Symptomatic cerebral syndrome with NMOSD-typical brain lesions
Differences between NMOSD and MS
NMOSD usually severe attacks restricted to optic nerve and spinal cord, long segments of spinal cord lesions with pleocytosis during attack. Oligoclonal bands usually absent. Have serum NMO antibodies
What effect does MS treatment have in NMOSD?
usually worsens disease
NMOSD treatment
PLEX + steroids
MMF / Azathioprine
Rituximab
Emerging therapies: IL-6 blockade, Complement pathway blockade (eculizumab), anti-CD19 MAB
MOG antibody disease antibody
myelin oligodendrocyte glycoprotein (MOG)
MOGAD treatment
treat as per NMOSD
MS treatment
Most for relapsing remitting MS
Natalizumab
- trial
- target
- effect
- precautions
AFFIRM trial
MAB that targets integrin found on monocytes and lymphocytes
70% reduction in relapse rate, 90% reduction in MRI activity
PML - (JCV)
Alemtuzumab
- trial
- target
- effect
- precautions
CARE-MSI
binds CD52 found on all differentiated lymphocytes and monocytes
reduces risk by 50% compared to interferon based treatment
infusion reactions common, new autoimmune disease, infection risk increased
Ocrelizumab
- trial
- target
- effect
- precautions
OPERA I and II
anti-CD20
Reduces relapses by 50% compared to IFN
infusion reactions, HBV reactivation, PML (low)
Ofatumumab
- target
anti-CD20
Cladribine
- target
- effect
- precautions
deoxyadenosine analogue prodrug that selectively targets lymphocytes due to preferential intracellular activation
Reduces relapse rate by 50%
VZV
Fingolimod
- target
- effect
- precautions
S1P receptor on lymphocytes, blocking egress from lymph nodes
reduces relapse rate by 50%
Bradycardia, LFT derangement, lymphopenia, herpes virus reactivation, PML risk
Ozanimod
- target
- effect
-
Sphingosine-1-phosphate inhibitor
similar efficacy to fingolimod
no cardiac monitoring
Dimethyl fumarate
- target
- effect
- risks
modulates antioxidative pathways via activation of Nfr2
45-55% reduction in relapses
SE: flushing, GI symptoms, LFT derangement
Diroximel fumarate
similar to dimethyl fumarate but less GI symptoms
Teriflunomide
- target
- effect
- SE
inhibits dihydroorotate dehydrogenase and interferes with pyrimidine synthesis
reduces relapses by 30%
SE: hepatotoxicity, hair thinning, hypertension, teratogenic
Only therapy listed for secondary progressive MS
siponimod
Pregnancy and MS
MS relapses fall during pregnancy but increases in 3 months post partum
Use glatiramer or dimethyl fumarate, consider natalizumab
