Multiple Sclerosis

Question 1

MS is a _________ (acute/chronic), _________-mediated, demyelinating ___________ condition of the CNS which affects the _______, ________ nerves, and ____________ and leads to progressive severe disability.

Answer 1

Chronic

Immune

Inflammatory

Brain

Optic

Spinal cord

Question 2

_________-__________ MS is the most common pattern of disease

Answer 2

Relapsing-remitting

Question 3

Relapsing-remitting MS is characterized by…?

Answer 3

…periods of exacerbation of symptoms (relapses) followed by unpredictable periods of stability (remission).

The severity and frequency of relapses varies greatly between patients, but on average occur once or twice per year.

Question 4

Relapsing-remitting MS often develops into _________-_________ MS, which is characterized by…?

Answer 4

Secondary-progressive

…progressive disability unrelated to relapses. Most patients develop secondary-progressive disease 6-10 years after onset

Question 5

Most patients develop secondary progressive disease _______ years after the initial onset of MS.

Answer 5

6-10

Question 6

________-__________ multiple sclerosis follows a gradual course, with the development of symptoms that worsen over time, without relapses and remissions.

Answer 6

Primary-progressive

Question 7

_________-________ multiple sclerosis follows a course of steadily worsening neurological function from onset, in addition to acute relapses.

Answer 7

Progressive-relapsing

Question 8

Disease activity in RR-MS: “Active” disease is defined as at least ____ clinically significant relapses occurring within the last ___ years.

Answer 8

Two

Two

Question 9

Disease activity in RR-MS: “Highly active” disease is characterised by an __________/_________ relapse rate or by ongoing ________ relapses compared with the previous year, despite treatment with interferon beta.

Answer 9

unchanged/increased

severe

Question 10

Disease activity in RR-MS: “Rapidly-evolving severe” relapsing-remitting multiple sclerosis is defined by _____ or more disabling relapses in ____ year(s), and _____ or more gadolinium-enhancing lesions on brain magnetic resonance imaging (MRI) or a significant increase in T2 lesion load compared with a previous MRI.

Answer 10

2

1

1

Question 11

Is there a cure for MS?

Answer 11

No, the aim of treatment is to modify the disease course and manage symptoms in order to improve QoL. Treatment is aimed at reducing the frequency and duration of releases and preventing or slowing disability

Question 12

Shared decision-making between the patient and their clinicians is particularly important in the treatment of multiple sclerosis, due to the _____________ of the condition and the lack of evidence of __________________

Answer 12

unpredictability

long-term benefit of treatments

*A discussion about treatment options, disease activity, risk, and benefit should take place to ensure that treatment choices are right for the patient and their circumstances

Question 13

In the management of MS, treatment should be initiated ____________ (early/late) in the disease, under specialist supervision

Answer 13

As early as possible

Question 14

Which 7 drugs are licensed for use in the treatment of MS in England?

Answer 14

1. Interferon beta
2. Glatiramer acetate
3. Fingolimod
4. Natalizumab
5. Teriflunomide
6. Dimethyl fumarate
7. Alemtuzumab

Question 15

Low levels of vitamin ___ are believed to be a risk factor for developing multiple sclerosis.

Answer 15

D

Patients with diagnosed multiple sclerosis are usually given regular vitamin D after assessment of their serum levels of vitamin D, but there is insufficient evidence to support its use as a treatment for multiple sclerosis

Question 16

Should patients be offered Vit D for the treatment of MS?

Answer 16

No, not unless they are also deficient

Question 17

_________-________drugs are the recommended treatment for patients presenting with active relapsing-remitting multiple sclerosis.

Answer 17

Disease-modifying

Question 18

___________ and ____________ are the disease-modifying drugs of choice in the treatment of active relapsing-remitting MS

Answer 18

Interferon beta

Glatiramer acetate

Second line:

• peginterferon beta-1a as an alternative to non-Peggy later interferon therapies
• teriflunomide (NOT for highly active disease)
• dimethyl fumarate (NOT for highly active disease)

Question 19

___________ or ____________ are the drugs of choice for the treatment of more active disease in patients with MS.

Answer 19

Natalizumab (safer)

Alemtuzumab (reports of serious CV and immune-mediated reactions)

Question 20

Natalizumab is only recommended for the treatment of _________-_________ _________ relapsing-remitting MS

Answer 20

Rapidly-evolving severe

Question 21

____________, ____________ and ________________ may be preferred due to their oral route of administration in patients with active MS.

Answer 21

Teriflunomide (NOT for highly active disease)

dimethyl fumarate (NOT for highly active disease)

Fingolimod (for highly active disease)

Question 22

Currently, only ______________ is licensed for use in secondary progressive multiple sclerosis.

Answer 22

interferon beta 1b;

reduces the risk of relapse and of short-term relapse-related disability, but does not prevent the development of permanent physical disability or retard progression once it is established

Question 23

What disease-modifying treatments are licensed for use in primary progressive MS?

Answer 23

Currently no effective disease-modifying treatments

Interferon beta [unlicensed indication] has been used, but there is limited evidence to support its use due to the lack of a significant reduction in disability progression.

Question 24

What disease-modifying treatments are licensed for use in progressive-relapsing MS?

Answer 24

Currently no specific treatment options

Question 25

What are the chronic symptoms of MS?

Answer 25

1. Neurological dysfunction
2. Fatigue
3. Spasticity
4. Visual problems
5. Emotional lability

Question 26

____________ may increase the progression of disability in multiple sclerosis

Answer 26

Smoking; smoking cessation should be encouraged

Question 27

_________________ are recommended for reducing inflammation and accelerating recovery in acute relapses of relapsing-remitting multiple sclerosis

Answer 27

Corticosteroids, oral methylprednisolone is first-line;

However, these are NOT considered disease-modifying

Question 28

Oral _____________ is recommended as the first-line option in treating acute relapses of relapsing-remitting MS

Answer 28

methylprednisolone

IV should be considered as an alternative if oral has failed or is not tolerated or if hospitalization is required

Question 29

_______________ may have beneficial effects on mobility and fatigue in patients with multiple sclerosis, and should be encouraged

Answer 29

Regular exercise

Question 30

__________________ for fatigue should also be considered in combination with exercise in the management of MS

Answer 30

Cognitive behavioural techniques

Question 31

__________________ [unlicensed indication] may be used to treat fatigue related to multiple sclerosis

Answer 31

Amantadine hydrochloride

Question 32

Are Vit B12 injections recommended as a treatment for fatigue in patients with MS?

Answer 32

No

Question 33

_____________ is licensed for the improvement of walking in patients with multiple sclerosis who have a walking disability.

Answer 33

Fampridine

However, NICE do not consider it to be a cost-effective treatment and do not recommend its use.

Question 34

Many factors may aggravate spasticity in multiple sclerosis, including _________, _________, ___________, ___________, ________ and _______

Answer 34

constipation

infection

poor mobility aids

pressure ulcers

posture

pain

Question 35

The first-line options for managing spasticity in multiple sclerosis are __________ or _________

Answer 35

baclofen

gabapentin [unlicensed indication]

Second line:

• tizanidine
• dantrolene

Third line:
- benzodiazepines (also effective in treating nocturnal spasms)

Question 36

A 4-week trial of ______________ can be offered as adjunctive treatment for moderate to severe spasticity in multiple sclerosis if other pharmacological treatments are not effective

Answer 36

cannabis extract

Question 37

__________ is the first-line treatment for oscillopsia in MS

Answer 37

Gabapentin [unlicensed indication]

Second line: memantine

Question 38

_____________ may be used to treat emotional lability in patients with MS

Answer 38

Amitriptyline (unlicensed)