MS management Flashcards
MS usually begins
begin the ages of 20-40
early course of MS is usually
relapsing/remitting
what is the Prevalence of MS in vancouver compared to malta
vancouver 91/100,000
Malta 4/100,000
what is the comparative risk for developing MS based on race in USA
White males 1.0
Black males 0.43
Other males. 0.22
what are the ratios of male to female cases of MS?
early onset 3 females :1 male
normal range 2 F: 1 M
Late onset 2.4 F: 1 M
MS prevalence can be altered by..
a change in environment
age of migration is critical for risk retention
according to Sadovnick et al 1993 what are the rates of concordance for MZ, DZ and siblings?
31% MZ, 5% DZ, 5% siblings
what components of the Immune system are thought to play a role in MS pathogeneis?
Lymphocytes (B&T)
Monocytes/macrophages
what qualities do remyelinating neurons axons have?
uniformly thin, short internodes
plaque distribution in the cerebral hemispheres relates to what symptoms
large variety of symptoms but also many silent lesions
plaque distribution in the spinal cord leads to what symptoms?
weakness, paraplegia, spasticity, tingling, numbness, lhermitte’s sign, bladder and sexual dysfunction
plaque distribution in the optic nerves leads to what symptoms?
impaired vision, eye pain
plaque distribution in the medulla and pons leads to what symptoms?
dysarthria, double vision, vertigo, nystagmus
plaque distribution in the cerebellar white matter leads to what symptoms?
Dysarthria, nystagmus, intention temor, ataxia
what are 6 typical symptoms/signs of MS
optic neuritis
spasticity and other pyramical signs
sensory signs and symptoms
lhermitte’s sign
nystagmus, double vision and vertigo
bladder and sexual dysfunction
what are the symptoms of optic neuritis?
impaired vision and eye pain
what are 5 atypical symptoms or signs of MS?
aphasia
hemianopia
extrapyramidal movement disturbance
severe muscle wasting
muscle fasiculation
what is the outcome when lesions affect the cranial nerves?
optic neuritis and other cranial nerve symptoms
diplopia and uhthoff’s phenomenon
what is the outcome when MS lesions affect the motor systems?
spasticity, weakness,temor and ataxia
what is the outcome when lesions affect the sensory systems?
many symptoms including lhermitte’s sign
what is the outcome when lesions affect autonomic systems
bladder, bowel and sexual dysfunction
what are the symptoms when the neurobehavioral systems are affected
cognitive problems and depression
what qualities are seen on the CSF electrophoresis in MS?
IgG oligoclonal bonds
what is one feature of a preclinical phases of MS
radiologically isolated sydrome
describe the prognosis of MS
less than 5-10% will have a mild phenotype with no significant disability
More than 30% of patients will develop significant disability within 20-25 years after onset
Life expectancy is shortened only slightly in persons with MS
Survival rate is linked to disability
Death usually results from secondary complications (pulmonary or renal)
Marburg variant is an acute and clinically fulminant form of the disease that can lead to coma or death within days
name 6 clinical indicators of poor prognosis
Male gender Late age at onset Early motor, cerebellar, and sphincter symptoms Short inter-attack interval High number of early attacks Early residual disability
name 4 paraclinical indicators of poor prognosis in MS
Significant MRI disease burden at onset
Evidence of MRI disease activity
Positive cerebrospinal fluid analysis for OCB
Positive evoked potential examination
what treatment modalities exist for MS?
IMMUNOMODULATORY THERAPY Acute repulses Frequent relapses Aggressive illness Progressive illness
MANAGEMENT OF SYMPTOMS
NON PHARMACOLOGICAL TREATMENTS
physiotherapy
occupational therapy
what can be useful to hasten recover from acute exacerbations?
Oral or intravenous Methylprednisolone (steroids)
no evidence that this changes the overall disease progression
does not affect outcome but may shorten relapse
when should plasma apheresis be used to treat MS?
short term for severe attacks if steroids are contraindicated of ineffective
2011 AAN guidelines (“probably effective”) as a second line treatment
symptoms management can be used to treat which symptoms
can be pharmacological or non pharma
Fatigue Spasticity Bladder problems Bowel problems Cognitive dysfunction Pain Paroxysmal symptoms Sexual dysfunction Tremor
patients with MS may benefit from referral to who?
Patients with MS may benefit from referral to
Physiotherapists
Occupational therapist
Speech therapists
what should you do when patients have bad prognostic markers?
Treat early
Treat aggressively
what is the prevalence of MS?
120-180/100,000 in britain depending on location
what do Disease Modifying Therapies (DMTs) aim to do?
reduce the frequency and severity of relapses
what is urthoffs phenonomenon?
worsening of neurological symptoms of demyelinating diseases such as MS from overheating
what is the definition of a relapse in MS?
24 hours 1 month apart
- where infection is ruled out
what are the 2008 sheffield definitions of a clinically significant relapse in MS?
1) Any Motor relapse
2) Any Brainstem relapse
3) A Sensory relapse leading to functional impairment
4) Sphincter dysfunction
5) Optic Neuritis
6) Intrusive pain
what is the sheffield 2008 definition of a disabline relapse in MS?
1) Affects the patient’s ability to work
2) Affects the patient’s activities of daily living
3) Affects motor or sensory function sufficiently to impair the capacity or reserve to care for themselves or others
4) Requires treatment/hospital admission
do Disease Modifying Therapies have an effect on disease progression?
no but can reduce relapses and relapse related disability
how to disease modifying therapies work?
by altering various mechanisms in the immune system to prevent an inflammatory response
ie immune modulators
preventing cells crossing blood brain barrieer ( natalizumab)
keep lymphocytes in the lymph tissue
reduce lymphocyte formation (teriflunomide, azothiprine)
reboot immune system
(bone marrow transplant)
describe the evidence from trials for disease modifying therapies
evidence from BENEFIT (betaferon) and PRECISE (copaxone) that they delay time to conversion after clinically isolated syndrome (teriflunomide too)
describe the four common first line DMTs in MS and how their effect
interferon beta 1a IM
interferen beta 1b SC
interferon beta 1a SC
Capaxone (galtimarmer acetate)
all 4 reduce relapses by about a third
make relapses milder
interferons may have some effect on slightly slowing disease progression
what are some potential side effects of interferons?
skin site reactions flu like symptoms leucopenia anaemia thrombocytopeinia liver dysfunction potentially teratogenic can cause depression ( and suicide)
what some of the newer DMDs?
ORALS
teriflunomide
dimethylfumarate
NON ORAL
fingolimod
natalizumab
alemtuzumab
what sort of stem cell treatments are already used to tream MS?
autologous (self) bone marrow transplants
how can vitamin d be used as a DMT?
diet supplementation
may act altering DRBI*1501
study in 132 hispanic people found that lower vitamin d experienced more relapses
in terms of efficacy which drug is weakest and which is strongest?
laquinimod weakest
mitoxantrome strongest
which DMTs are least and most convenient?
vitamins , anticonvulsants, and drugs such as teriflunomide are the most convenient (oral)
IV are least convenient such as natalizumab and mitoxantrone
