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Pharmacotherapy III > MS - Ott > Flashcards

MS - Ott Flashcards

1
Q

What are the criteria for diagnosing MS?

A

Dissemination in time – 2 new lesion of 30 days, evidence that damage has happened more than once
Dissemination in space – >1 lesion in at least 2/4 typical regions

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2
Q

What is NMOSD?

A

Disease similar to MS - more common in AA, Asian, Latin American, children

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3
Q

What is CIS?

A

First demyelinating event involving optic nerve, cerebrum, cerebellum, or spinal cord

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4
Q

What percentage of patients progress to SPMS?

A

80%

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5
Q

Who si more likely to have PPMS?

A

Patients diagnosed later in life

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6
Q

What is the least common MS?

A

Progressive Relapsing MS

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7
Q

What is PRMS?

A

Steadily worsening disease from onset with clear relapses, but no remission between relapses

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8
Q

What scale is used to assess MS treatment efficacy?

A

EDSS - expanded disability status scale

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9
Q

How long does it take to progress to SPMS from RRMS?

A

20-25 years

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10
Q

How to treat acute attacks? Inpatient

A

Methylprednisolone 500-1000 mg IV daily for 3 to 7 days with taper over 1-3 weeks (oral)

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11
Q

How to treat acute attacks? outpatient

A

Prednisone 1250 mg every other day x 5 doses

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12
Q

How to treat acute attacks? w/ optic neuritis

A

IV methylprednisolone

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13
Q

T/F: Most MS drugs have a noticable effect in patient

A

FALSE: Most drug effects cannot be seen by patient in short-term; counsel on importance of long-term benefits!

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14
Q

First-line RRMS treatment?

A

InterferonB1a, InterferonB1b, Glatiramer acetate, fingolimod

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15
Q

First/second line RRMS treatment?

A

Teriflunomide

Dimethyl fumurate

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16
Q

Second line RRMS treatment?

A

natalizumab

mitoxantrone

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17
Q

Treatment-resistant MS option?

A

alemtuzumab

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18
Q

PPMS treatment?

A

Ocrelizumab

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19
Q

What types of MS is ocrelizumab used to treat?

A

PPMS and RRMS

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20
Q

Ocrelizumab is contraindicated with ___

A

Active hepatitis B infection

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21
Q

Ocrelizumab has an increased risk of ___

A

malignancies

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22
Q

What drug class can cause flu-like symptoms?

A

iNterferons

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23
Q

What patient population is most likely to experience flue-like symptoms as an ADE?

A

Females with low BMI

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24
Q

How can you reduce flu like symptoms?

A

Give at night to sleep through symptoms; take OTC pain reliever 4-6 hours before injection; titrate dose

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25
Q

Injection site reactions occur with what medications?

A

Interferons, glatiramer

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26
Q

Lipatrophy occurs with what drug?

A

Glatiramer

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27
Q

How do you reduce injection site reactions?

A

Warm compresses or ice before injection; warm med to room temperature; ensure needle completely penetrates skin

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28
Q

What are post-injection reactions?

A

Facial flushing, chest tightness, dyspnea, palpitations, anxiety

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29
Q

How do you treat post-injection reactions?

A

you don’t

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30
Q

Which medication has a life-threatening infusion reaction? What do you do about it?

A

alemtuzumab

Monitor pt for 2 hours post-infusion

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31
Q

What medications have infusion reactions?

A

alemtuzumab

ocrelizumab

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32
Q

How can you decrease ocrelizumab’s infusion reaction?

A

Premedicate with corticosteroid/antihistamine/antipyretic

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33
Q

What is PML?

A

Reactivation of JCV that causes neurobehavioral, motor, language, and cognitive changes, seizures, tremor - can look like MS relapse

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34
Q

What drugs cause PML?

A

Natalizumab (black box warning)
Fingolimod
Dimethyl fumarate

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35
Q

How can you avoid PML?

A

Test for JCV antibodies before injection

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36
Q

What are contraindications to natalizumab?

A

Viral hepatitis
Malignancy
Inability to have MRI
immunocompromised

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37
Q

Alemtuzumab has what side effects?

A

thrombocytopenia, basement membrane disease, increased risk of malignancies

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38
Q

Alemtuzumab is contraindicated with what?

A

HIV infection

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39
Q

You should avoid dosing alemtuzumab when?

A

In patient with active infection - until infection is fully controlled

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40
Q

Ocrelizumab has what warning?

A

Increased malignancy

41
Q

Why is alemtuzumab not first line?

A

It has LOTS of ADEs - only use if other MS drugs fail

42
Q

Daclizumab is contraindicated with what/

A

Hepatitis or hepatic impairment

43
Q

What medications need to avoid live vaccination?

A

Alemtuzumab, daclizumab, fingolimod, ocrelizumab, teriflunomide

44
Q

Before initiating daclizumab, evaluate for ___

A

TB

45
Q

What drugs are associated with cardiac adverse effects?

A

Fingolimod

Mitoxantrone

46
Q

Fingolimod can cause _____. How do you monitor?

A

reduction in HR, heart block
In clinic for 6 hours after initial dose w/BP monitoring
If CV risk factors - keep for 24-hour EKG

47
Q

Who should not receive fingolimod b/c of heart effects?

A

Patients with sinus bradycardia or heart block and no pacemaker

48
Q

What does mitoxantrone cause (cardiotoxicity)?

A

reduced LVEF, CHF; monitor EF

49
Q

What is pseudobulbar affect?

A

Inappropriate responses to situation

50
Q

What is used to treat pseudobulbar affect?

A

Neudextra

51
Q

What is in Neudextra?

A

DM

Quinidine

52
Q

How does Neudextra work?

A

Dextromethorpahan agonist suppresses release of excitatory NTs and agonizes sigma-1 receptors
DM is metabolized to dextrorphan by P450
Quinidine inhibits P450 –> more DM

53
Q

How do you treat gait abnormalities?

A

PT

Dalfampridine

54
Q

Dalfampridine MOA?

A

Blocks K channels –> prolonged AP

55
Q

Side effects of dalfampridine? ER

A 
UTI
Insomnia
HA
Dizziness
Nausea
56
Q

Side effects of dalfampridine? IR

A

Seizures

57
Q

Which drugs are category X?

A

Teriflunomide - avoid for 2 years after stopping drug

58
Q

Which drugs are category D?

A

Mitoxantrone - pregnancy test before each infusion

59
Q

Which drugs are category B?

A

Glatiramer

60
Q

Which drugs are category C?

A

All others

61
Q

If I’m taking fingolimod and want to get pregnant, what do I do?

A

D/C fingolimod for 2 months before pregnancy (long half life)

62
Q

Can I keep taking MS therapy while pregnant?

A

No - D/C before conception

63
Q

What is considered treatment failure?

A
  1. No decrase in relapse rates
  2. Acquired disabilities (EDSS score changed by 1 point in one year)
  3. MRI activity (new lesions)
64
Q

What can medical marijuana be used for w/MS?

A

Spasticity (OCE/THC)

Central pain/painful spasms (OCE/THC)

65
Q

How do you treat bladder dysfunction w/MS? What is the downside?

A

anticholinergics (oxybutynin, tolteridone)

May worsen cognitive dysfunction

66
Q

What is the most common side effects with MS?

A

Bladder dysfunction

67
Q

How do you treat bowel dysfunction (constipation) with MS?

A

Bulk-forming agents (methylcellulose, psyllium), stool-softeners
Adequate fluid/fiber in diet

68
Q

How do you treat cognitive dysfunction?

A

NOT memantine or cholinesterase inhibitors

DMDs may slow decline

69
Q

How to treat pseudobulbar affect?

A

DM/quinidine

70
Q

What percentage of patients develops pseudobulbar affect?

A

10%

71
Q

What symptom do 50-60% of patients report as the WORST of their disease?

A

Fatigue!

72
Q

How do you treat fatigue?

A

Rule out drug effects/side effects, other problems (depression, sleep, metabolic disorders)
Amantadine

73
Q

How do you treat gait impairment?

A

Dalfampridine (improves walking speed by 35%)

74
Q

How do you treat neurogenic pain?

A

Anticonvulsants (gabapentin, pregabalin, lamotrigine, levetiracetam, carbamazepine, ocxarbazepine)
Duloxetine
TCAs
Oral cannabis extract

75
Q

What can worsen spasticity?

A 
Sudden movement
Change in position
Extreme temperature
Humidity
Infections
Tight clothing
76
Q

Where does spasticity occur?

A

Legs

77
Q

How to treat spasticity?

A

Regular stretching/exercise
Baclofen, tizanidine, diazepam, clonazepam, dantrolene
Oral cannabis extract
Tetrahydrocannabinol (THC) - for painful spasms

78
Q

What percentage of patients have sexual dysfunction?

A

60-70%

79
Q

Avonex dose (B1a)

A

30 mcg IM once weekly

80
Q

Rebif dose (B1a)

A

22 or 44 mcg SC three times weekly

81
Q

Betaseron/Extavia dose (B1b)

A

250 mcg sc every other day

82
Q

Peginterferon dose

A

Titration to 125 mcg SC every 14 days

83
Q

Glatiramer acetate dose

A

20 mg sc qd

84
Q

fingolimod dose

A

0.5 mg po daily

85
Q

Teriflunomide dose

A

7 mg or 14 mg orally once daily

86
Q

Dimethyl fumarate dose

A

240 mg DR BID

87
Q

Natalizumab dose

A

300 mg IV every 4 weeks

88
Q

Mitoxantrone dose

A

12 mg/m2 IV every 3 months

89
Q

Alemtuzumab dose

A

IV over 4 hours
1st course: 12 mg/day x 5
2nd: 12 mg/day x 3 days (12 months after 1st)

90
Q

What meds are given with alemtuzumab?

A

Corticosteroid (prior to infusion x 3 days)

Antiviral agent on 1st day of dosing x 2 months OR until CD4 >200 cells/mL

91
Q

Daclizumab dose

A

150 mg SC once monthly

92
Q

Ocrelizumab

A

600 mg in 500 mL IV over at least 3.5 hours every 6 months

93
Q

What meds are given with ocrelizumab?

A

Methylprednisolone 100 mg + Antihistamine 30-60 minutes before first infusion

94
Q

Side effects of interferons?

A 
Depression
Flu like symptoms
Injection site reactions
psychosis
Hepatotoxicity
Worsening CHF
thryoid dysfunction
Seizures
Thrombotic microangiopathy
95
Q

Side effects of glatiramer acetate?

A 
Infection
Hypersensitivity
Chest tightness
Flushing
Urticaria
Rash
96
Q

Which medication is monotherapy only?

A

Natalizumab

97
Q

Lifetime dose of mitoxantrone should not exceed what?

A

140 mg/m2

98
Q

When is fingolimod contraindicated?

A

Stroke/heart attack
2nd or 3rd degree AV block
QT interval prolongation
decompensated CHF

Pharmacotherapy III (12 decks)

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