MS Flashcards
What vitamin plays a role in MS development?
Vitamin D
Diagnosing MS
Separated by time and space:
- At least 2 documented clinical exacerbations
- At least 2 MRI lesions
PPMS diagnosis
One year of disease progression plus 2 of the following:
- DIS in the brain
- DIS within the spinal cord
- Positive CSF
CIS diagnosis
1 exacerbation (24h+) and 1 lesion
RRMS
- Most common (85%)
- periodic worsening of symptoms followed by remissions
SPMS
- Decreased incidence due to modern medicine
- Relapsing/remitting becomes steady progression
PPMS
- Rare (10%)
- Steady decline without relapses
- Medications generally not effective
PRMS
- Rarest (5%)
- Steady disease progression in addition to exacerbations (RR)
- Exacerbations can be treated with steroids BUT disease still progresses
Acute MS exacerbation treatment
Corticosteroids*
- Solumedrol (methylp.) IV followed by prednisone taper
(maybe corticotropin acthar gel)
H2b/PPI for ulcer prophylaxis
Monitor BP, watch for infection
ABCR injectables
Indicated for for CIS, RRMS, SPMS
Interferon beta-1a (Avonex, Rebif, Plegridy)
Interferon beta-1b (Betaseron, Extavia)
Glatiramer acetate (Copaxone, Glatopa)
Interferon beta
- Pregnancy category C
- FLU LIKE SYMPTOMS!! -> premedicate with APAP/ibuprofen, titrate up slowly
- Avonex given IM once weekly
- Rebif given SC three times weekly
- Plegridy given SC once weekly, peglyated
- Betaseron/Extavia given SC every other day
Glatiramer acetate
- Pregnancy category B*
- INJECTION SITE REACTION!!
Natalizumab (Tysabri)
Indicated for for CIS, RRMS, SPMS
- a4-integrin antagonist, humanized moAb
- Stops leukocytes from crossing BBB
- IV q4w
- Pregnancy category C
- PML risk!!***
- UTI, RTI, depression, GI issues, headache, arthralgia
Alemtuzumab (Lemtrada)
Indicated for RRMS and SPMS
- Reserved for inadequate response to 2+ medications
- moAb targets CD52 on T and B cells, resets immune system
- Pregnancy category C
- Premedicate with corticosteroids
- Stay in hospital for 5 days for IV infusion, then for 3 days in a year
- DEVELOPMENT OF AUTOIMMUNE THYROID DISORDERS (1/3 of pts) -> monitor TSH
- rash, HA, GI, infections, fatigue, malignancy
- BBW immune thrombocytopenia and anti-glomerular basement membrane disease
-> monitor CBC, SCr
- very serious infusion reactions
Ocrelizumab (Ocrevus)
Indicated for CIS, RRMS, SPMS, and PPMS**
- CD20 cell lysis of B cells
- Infusion reactions
- Hepatitis B reactivation
- Herpes infection
- Malignancy
- PML
Ofatumumab (Kesimpta)
Indicated for for CIS, RRMS, SPMS
- CD20 cell lysis of B cells
- Similar to ocrelizumab
- Subcutaneous -> patients can take home, pt friendly!
- Separate vaccines
- Infections, injection reactions, PML
Mitoxantrone
Indicated for SPMS, PRMS, or worsening of RRMS
- Breaks DNA, stops repair via topoisomerase II
- cardiotoxicity, bone marrow sup., GI, HA, alopecia
- max 100 mg/m^2 lifetime dose
Mavenclad (cladribine)
Indicated for RRMS and SPMS for those intolerant to other therapies
- Purine analog, prodrug, depletes ATP, decrease lymphocytes
- Max 3.5 mg/kg over 2 years
- Missed dose -> extend treatment cycle
- Lymphocytes must be WNL
- Teratogenic, malignancies
- CI in pregnancy, infection, malignancy
- PML, cardiotox, hepatotox, HA
Fingolimod (Gilenya)
Indicated for CIS, RRMS, SPMS >10 y/o
- S1P, depletes CD4, CD8 T cells
- oral therapy 0.5mg QD for RRMS and SPMS
- ECG needed for initiating
- Monitor CV
- HA, infection, macular edema, HTN, GI, pain
Mayzent (Siponimod)
Indicated for CIS, RRMS, SPMS
- S1P
- Lower dose for CYP2C9 genotype 1/3 or 2/3
- CONTRAINDICATED for 3/3
- infections, PML, macular edema, CV, QT, malignancy, hepatotox, HTN
- CYP2C9 DDI
- Additional monitoring for pt with sinus bradycardia (<55 HR), AV blokc, MI, HF
Ozonimod (Zeposia)
Indicated for CIS, RRMS, SPMS
- S1P
- Oral dosing
- CV contraindications
- CV ADEs, infection, hepatotox, macular edema, neurotox, PML
- tyramine -> hypertensive crisis
Teriflunomide (Aubagio)
Indicated for CIS, RRMS, SPMS
- cytostatic effect on T and B cells
- food affects absorption
- HA, pain, infections, alopecia
- BBW hepatotox, teratogenicity (even in semen)
- decrease concentration with cholestyramine
Dimethyl fumarate
Indicated for CIS, RRMS, SPMS
- Cytokine induction -> T cell apoptosis
- GI SYMPTOMS!! (with/without food)
- flushing (take with ASA), PML
- Vulmerity less GI effects than Tefidera
- Monomethyl fumarate (Bafiertam) also has less GI effects
Drugs to treat spasticity in MS
- Baclofen
- Dantrolene
- Diazepam, clonazepam
- Tizanidine
- Gabapentin, pregablin, tiagabine
- Botox
- Dalfampridine
