MS Lectures Flashcards
Between what ages are most MS patients diagnosed?
20 - 40yrs
Women are affected by MS at higher frequencies (3:1) than males; which gender typically has a more severe disease course?
Males
What is the underlying pathophysiology of MS?
Immune trigger causes inflammation, leading to demyelination & axonal degeneration within the CNS.
Sx of MS?
-Numbness / Tingling
-Vision Problems
-Fatigue
-Brain Fog
-Trouble Walking
-Bladder / Bowel Issues
-Pains / Weakness
-Muscle Spasms
What is “Lhermitte’s Sign”?
Chin tilted downwards & shooting pains running down the spinal column.
Describe “Uhtohoff’s Phenomenon”.
Heat intolerance that worsens typical symptoms; heat avoidant behaviors also commonplace.
What is the “MS Hug”?
Numbness & tightness around the midsection.
Four types of MS?
1) Relapse-Remitting (85%)
2) Secondary Progressive (most with RR go on to develop this; 10-15yrs common timeframe of development)
3) Primary Progressive (10-15%; more commonly seen with men)
4) Clinically Isolated Syndrome (CIS)
T or F: Inflammation is typically lower in more advanced MS presentations.
True… High during relapses / remission episodes, then lower as disease worsens.
Why are drug studies related to MS medications limited in terms of applicability?
Only look at patients with EDSS scores < 6… More severe MS presentations lack data on effectiveness!
What defines a true MS relapse?
-Lasts >/= 24hrs.
-No fever / infection.
-Must be >/= 30d since previous episode.
What is the treatment for an MS relapse?
1) Methylprednisolone 500-1000mg IV x 3-5d
OR
2) Prednisone 1250mg po x 3-5d
If a relapsing MS patient is non-responsive to high dose corticosteroids, what can be done?
Plasma Exchange
Amantadine, Modafinil & Methylphenidate can all be used to treat MS-related fatigue; describe their side effect profiles.
Amantadine: Insomnia & sleep disturbances.
Modafinil: Headache, insomnia, SJS, fetal abnormalities.
Methylphenidate: Insomnia, anxiety, dizziness.
Name of the shitty drug that can be used (on occasion) for MS-related Gait?
Fampridine
Drugs for treating MS-related muscle spasms?
Baclofen
Gabapentin
Botox
How often is Botox dosed for treating MS spasticity?
q3-6mths
Sativex (1:1 THC to CBD) is a cannabinoid drug used to treat spasticity & pains related to MS; what dosage form does it come in?
Buccal Spray
Potential ADRs of Sativex?
-Fatigue
-LT Cognitive Effects
-Increased HR
-Dizzy
-Blurry Vision
-Falls
What was the very first DMT drug that came to market for treating MS?
Betaseron (IFN beta-1b)
Which DMT drug is the only commercially available option with an official indication for treating Primary Progressive MS?
Ocrevus (Ocrelizumab)
Which DMT drug is the only commercially available option with an official indication for treating Secondary Progressive MS?
Mayzent (Siponimod)
What is the newest DMT drug available for treating MS?
Ponvory (Ponesimod)
List all the injectable DMT drugs for treating MS.
“PIIGO”
P - Peginterferon beta-1a
I - Interferon beta-1a
I - Interferon beta-1b
G - Glatiramer Acetate
O - Ofatumumab
List all the oral DMT drugs for treating MS.
“DTF COPS”
D - Dimethyl Fumarate
T - Teriflunomide
F - Fingolimod
C - Cladribine
O - Ozanimod
P - Ponesimod
S - Siponimod
List all the infused DMT drugs for treating MS.
“ARON”
A - Alemtuzumab
R - Rituximab
O - Ocrelizumab
N - Natalizumab
Of all the MS drugs, which are considered to be the weakest agents?
Interferon beta-1a
Interferon beta-1b
Glatiramer Acetate
Which of the MS drugs are considered to be the strongest agents (due to suppression of both B + T Cells) & thus pose the greatest worry in cases of infection?
Alemtuzumab
Cladribine
Due to its unique MOA (preventing lymphocytes from crossing into CNS), which MS drug would be problematic in cases of meningitis?
Natalizumab
Which three MS drugs work by inhibiting CD20 lymphocytes?
Ocrelizumab
Ofatumumab
Rituximab
Which MS drug works by decreasing CD40 B + T Cell activation?
Dimethyl Fumarate
Describe what “Progressive Multifocal Leukoencephalopathy” (PML) is.
Condition whereby opportunistic JC virus infections lead to destruction of the cells that produce myelin.
Is there a cure for PML?
Nope (& oftentimes fatal, making it very dangerous)… Only hope is plasma exchanges & stoppage of afflicting medication (pray that immune system jumpstarts itself).
What four MS drugs can cause PML?
“FOND”
F - Fingolimod
O - Ocrelizumab
N - Natalizumab
D - Dimethyl Fumarate
How often is Betaseron (Interferon beta-1b) injected? What delivery system does it come in?
EOD; SC injection
How often is Avonex (Interferon beta-1a) injected? Rebif (Interferon beta-1a)? Describe each’s delivery system too…
Avonex: IM qwkly
Rebif: SC 3x / week
How often is Plegridy (Peginterferon beta-1a) injected? What is its delivery system?
SC q2wks
All three interferon type injectables have the same adverse effects; what are they?
Injection Site Rxn
Flu-Like Sx
Liver Toxicity
Lymphopenia
Describe Copaxone 20, Copaxone 40, & Glatect’s (Glatiramer Acetate) dosing frequency, as well as their delivery systems.
Copaxone 20: SC QD
Copaxone 40: SC 3x / wk
Glatect: SC QD
Prominent ADR that should be monitored for with Glatiramer Acetate drugs?
Lipoatrophy
Describe Kesimpta’s (Ofatumumab) injection frequency, as well as its delivery system.
Week 1-3: SC qwkly
Thereafter: SC q4wks
How often is Aubagio (Teriflunomide) dosed? Tecfidera (Dimethyl Fumarate)?
Teriflunomide: QD
Dimethyl Fumarate: BID
Due to its dual-gender teratogenicity potential, how long should we tell Teriflunomide patients to use contraception?
2yrs post-drug usage
Important Dimethyl Fumarate ADRs / monitoring parameters?
Facial Flushing
Lymphopenias (CBCs)
How frequently is Gilenya (Fingolimod) dosed? Unique advantage of this drug?
QD; has a pediatric indication!
Important ADRs to monitor for with Fingolimod usage?
Slowed HR
Prolonged QTc
Given the cardiac side effects of Fingolimod, how long post-first dose do we need to conduct a cardiac observation?
6hrs post-first dose
T or F: All oral DMT drugs are teratogenic in nature & thus require baseline pregnancy tests.
False… Tecfidera (Dimethyl Fumarate) is not highlighted as teratogenic.
How frequently is Mayzent (Siponimod) dosed? What unique official indication does this drug have over others?
QD; Secondary Progressive MS.
Most oral agents have a 2-3mth washout period… How long is Siponimod’s?
10d
Due to its dual-gender teratogenicity potential, how long should we tell Mavenclad (Cladribine) patients to use contraception post-drug stoppage?
6mths post-last dose
Describe Cladribine’s weird dosing regimen.
Mth 1: 4-5d of 1 or 2 pills (depending upon weight)
Mth 2: 4-5d of 1 or 2 pills (depending upon weight)
Mths 3-12: No doses given (for a total of 8-10 doses over a year).
How often are Zeposia (Ozanimod) & Ponvory (Ponesimod) dosed?
QD
How often is Tysabri (Natalizumab) dosed? Ocrevus (Ocrelizumab)?
Natalizumab: q4wks
Ocrelizumab: Stat, wk 2, then q24wks thereafter
Important Natalizumab monitoring tests?
JCV status q6-12mths
Brain MRI q6-12mths
Ocrevus (Ocrelizumab) is commonly associated with infusion rxn’s… How many mins prior to infusions should we infuse with IV steroids & anti-histamines?
30-60mins
What would be an automatic contraindication to using Ocrelizumab?
Hep B infection (because drug can reactivate).
Ocrevus (Ocrelizumab) has a unique official indication compared to other DMTs… What is it?
Primary Progressive MS
A woman on Ocrevus (Ocrelizumab) is wanting to become pregnant & is preparing to stop her medication… How long should she wait post-last infusion to try becoming pregnant?
6-12mths
Lemtrada (Alemtuzumab) is associated with infusion rxn’s… Up to how many hours post-dosing can this appear?
2hrs post-dose
Alemtuzumab use is also associated with increased risk of developing autoimmune disorders (e.g. Thyroid, Skin, Nephropathies)… How long from the last dose given should we monitor these for?
4yrs
How many treatment courses of Alemtuzumab will the SK government cover?
Two; third treatment (if needed) is not covered.
What labs should a patient on Alemtuzumab be ordered for four years after the last dose given?
CBCs qmthly
Urinalysis + Cell Ct qmthly
TSH q3mths
Annual skin exams
Annual HPV / Cervical Dysplasia screens
What other MS drug (besides Fingolimod) has an official indication for use in pediatric patients?
Rituximab
What other two conditions (besides off-label use in MS) is Rituximab indicated for?
Non-Hodkin’s Lymphoma
Rheumatoid Arthritis
Rituximab is dosed stat & at 2wks, then q___mths thereafter.
6
Does an MS diagnosis affect a woman’s fertility potential? Does pregnancy worsen potential long-term disability?
Nope; nope.
Is it safe to give pregnant women IV Methylprednisolone in cases of symptomatic relapse?
Yep!
Although washout periods for many DMT drugs are necessary prior to becoming pregnant, will they make oral contraceptives less effective?
Nope (do not interact with one another).
Safest agents for use in pregnancy / breastfeeding?
Glatimer Acetate (Copaxone)
Interferon beta-1a & 1b preps (Betaseron, Avonex, Rebif, Plegridy)
Anti-CD20 MABs (Ocrelizumab, Ofatumumab, Rituximab; 2023 evidence goes against what was said in 2019)
An MS patient wants to update their influenza & Covid vaccines… How long from the onset of their last relapse should we wait before administering?
4-6wks from onset of last relapse
Can pharmacists in SK initiate EDS applications for MS patients?
Nope; has to be initiated by a physician, with cases reviewed by a panel of individuals.
What subtype of MS did Jess mention having?
Relapse-Remitting
What was the first symptom Jess described having?
Double vision driving to work
