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neurology/psychiatry > Multiple Sclerosis > Flashcards

Multiple Sclerosis Flashcards

1
Q

what type of disorder is MS

A

a chronic, inflammatory demyelinating disorder

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2
Q

age of diagnosis for MS

A

15-45 yo, peak incidence 4th decade

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3
Q

which gender more commonly has MS

A

women

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4
Q

factors that may be linked to MS

A

genetic: MS susceptibility genes (HLA class II)
environmental: late onset/severe childhood infections, viral infections

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5
Q

what might be a protective factor for MS

A

increased vitamin D

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6
Q

describe the pathophysiology of MS

A

auto-reactive T-lymphocytes are activated, cross into the CNS, and attack the myelin sheath of neurons— damaged myelin forms scar tissue (sclerosis)

T cells induce pro-inflammatory response in which cytokines further activate B cells/macrophages

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7
Q

what is the role of the myelin sheath?

A

a fatty substance surrounding and insulating neurons, necessary for proper signal transduction in CNS

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8
Q

what are PRIMARY MS symptoms?

A

visual complaints, gait problems, paresthesias, pain, spasticity, weakness, ataxia, speech difficulty, psychological changes, cognitive changes, fatigue, bowel/bladder dysfunction, sexual dysfunction, tremor

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9
Q

what is the relationship of heat sensitivity and MS

A

many people with MS experience worsening of symptoms with increased body temperature: cooling may help (cooling vests, etc)

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9
Q

what are secondary and tertiary MS symptoms

A

secondary: recurrent UTI, urinary calculi, decubiti, muscle contractures, resp infections, poor nutrition

tertiary: financial problems, personal/social problems, vocational problems, emotional problems

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9
Q

4 different subtypes of MS

A

relapsing-remitting: relapses with full recovery
secondary progressive: (following relapsing-remitting) disease progresses with or without occasional relapses/remissions/plateaus
primary progressive: progressive from onset
progressive relapsing: progressive from onset with acute relapses– with or without full recovery– continuous progression between relapses

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10
Q

what factors indicate a favorable prognosis in MS?

A

<40 years at onset
female
initial symptoms: optic neuritis or sensory symptoms
low attack frequency in early disease
relapsing/remitting course of disease

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11
Q

which factors indicate an unfavorable prognosis in MS?

A

> 40 years at onset
male
motor or cerebellar initial symptoms
high attack frequency in early disease
progressive course of disease

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12
Q

diagnosis/assessment of MS?

A

MRI: demyelination present
CSF: CNS IgG is increased, serum IgG normal
Oligoclonal bands (OCBs) are present
CEDSS: expanded disability status scale

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13
Q

3 broad treatment categories for MS

A

treatment of acute attacks
disease-modifying therapies
symptomatic therapy

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14
Q

how are acute exacerbations treated in MS

A

methylprednisolone 500-1000 mg/day IV x 3-5 days

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15
Q

which disease modifying therapies are PO

A

teriflunomide
dimethyl fumarate
diroximel fumarate
fingolimod
siponimod
cladribine

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16
Q

which disease modifying therapies are INJECTABLES (SQ)

A

interferon beta
glatiramer
ofatumumab

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17
Q

which disease modifying therapies are INFUSIONS (IV)

A

alemtuzumab
mitoxantrone
natalizumab
ocrelizumab

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18
Q

teriflunomide brand name

A

aubagio

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19
Q

dimethyl fumarate brand name

A

tecfidera

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20
Q

diroximel fumarate brand name

A

vumerity

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21
Q

fingolimod brand name

A

gilenya

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22
Q

siponimod brand name

A

mayzent

23
Q

cladribine brand name

A

mavenclad

24
Q

glatiramer brand name

A

copoxone

25
Q

ofatumumab brand name

A

kesimpta

26
Q

alemtuzumab brand name

A

lemtrada

27
Q

mitoxantrone brane name

A

novantrone

28
Q

natalizumab brand name

A

tysabri

29
Q

ocrelizumab brand name

A

ocrevus

30
Q

what do you know about teriflunomide

A

pregnancy category X, teratogen
drug interactions:
-CYP2C8: inc exposure of repaglinide/pioglitazone
-CYP1A2: dec exposure of fluoxetine, tizanidine
-may dec INR w/ warfarin

31
Q

what do you know about dimethyl fumarate

A

ADEs: flushing, GI effects
take w/ food for GI effects
take ASA 325 mg 30 minutes before dose for flushing
can cause lymphopenia: interrupt therapy if lymphocyte count <0.5 x 10^9 for 6+ months

32
Q

what do you know about diroximel fumarate

A

rapidly converts to mono-methyl fumarate, the same active metabolite as dimethyl fumarate– lower rates of GI effects

33
Q

what do you know about fingolimod

A

increased risk of life-threatening infections, tumor development: disseminated varicella zoster, herpes simplex encephalitis: BEFORE TREATMENT SHOULD HAVE VARICELLA SEROLOGY & ZOSTER VACCINE

less common but serious ADE: bradyarrhythmia, AV block

contraindicated in recent hx of MI, stroke, TIA, heart failure, second or third degree heart block, QTc>500 ms, use with class Ia or III antiarrhythmics (amiodarone/sotalol)

34
Q

what do you know about siponimod

A

contraindicated for CYP2C93/3 genotype
first dose monitor for bradycardia/arrhythmias
monitor liver function, BP during treatment
contraindicated in recent MI, unstable angina, advanced HF, AV block
AEs: dose-dependent bradyarrhythmia

35
Q

what do you know about cladribine

A

reserved for patients who do not tolerate or have inadequate response to other drugs for MS
lymphocyte counts should be monitored before, during, after treatment
each treatment course is two cycles of 4-5 days separated by 4 weeks
contraindicated in pregnancy, breastfeeding, women/men of reproductive potential (unless effective contraception for 6 months after)

36
Q

what do you know about interferon beta

A

causes flu-like symptoms (fever, chills, myalgias)
contraindicated in severe depression
counsel women to use appropriate contraception

37
Q

what do you know about glatiramer

A

causing transient chest tightness, flushing, dyspnea, if no hx CAD- self limited and benign
pregnancy category B

38
Q

what do you know about ofatumumab

A

requires HBV and quantitative serum immunoglobulins screening prior to treatment
dosing is 20 mg SQ at weeks 0,1,2
subsequent dosing 20 mg monthly starting at week 4
contraindicated in active HBV infection
counsel females to use effective contraception during treatment and for 6 months after stopping Kesimpta

39
Q

what do you know about alemtuzumab

A

due to safety profile, FDA recommends reserving for patients with inadequate response to two or more MS therapies
black box warnings for immune thrombocytopenia, serious & life-threatening infusion reactions, malignancies including thyroid cancer, melanoma, lymphoproliferative disorders

40
Q

what do you know about mitoxantrone

A

have to monitor EF before each dose and monitor for symptoms of CHF
Counsel patients it may impart blue-green color to urine, bluish color to sclera

41
Q

what do you know about natalizumab

A

it has a black box warning for increasing the risk of progressive multifocal leukoencephalopathy (PML): risk increases with number of infusions received
monitor JCV antibody every 3-6 months

42
Q

what do you know about ocrelizumab

A

approved for PPMS
targets CD20 positive B cells
ADEs are infusion reactions and infections (upper and lower resp tract, skin infections)

43
Q

counseling tips to tell your patients for injectables

A

-make sure the drug is at room or body temp before injecting
-ice the injection site before/after injecting drug
-never shake the vials
-rotate injection sites
-never inject the drug into an area that has a lump or a knot

44
Q

when does the national MS society recommend starting therapy?

A

immediately after diagnosis

45
Q

vitamin ____ deficiency is a common comorbidity with MS

A

D
consider obtaining a level and/or providing supplementation to every patient with MS

46
Q

drug used to improve walking/gait in MS?

A

dalfampridine (Ampyra) CNS potassium channel blocker

47
Q

what do you know about dalfampridine

A

take the tablets whole; do not crush, chew, etc
do not double or take extra dose due to seizure risk
contraindicated in history of seizures, moderate-severe renal impairment (CrCL<50)
drug interaction with metformin

48
Q

what drugs are recommended for spasticity in MS

A

baclofen, tizanidine

49
Q

what do you know about baclofen

A

GABA analog
must not be discontinued abruptly: hallucinations and seizure
KNOW THAT IT MUST BE TAPERED

50
Q

what do you know about tizanidine

A

centrally acting alpha adrenergic agonist
ADEs include hypotension, dry mouth

51
Q

what drugs are used for MS fatigue (“lassitude”)

A

amantadine (Symmetrel) 100 mg BID
Modafinil (Provigil) 100-400 mg daily

52
Q

drugs used for tremor in MS

A

propranolol, primidone

53
Q

drugs used for bowel/bladder issues in MS

A

hyperreflexic bladder (inability to store urine): oxybutynin, tolterodine
detrusor sphincter dyssynergia in men: alpha blockers (terazosin, doxazosin, tamsulosin)
constipation: fiber, laxatives, enemas

54
Q

depression drugs in MS

A

SSRIs are reasonable
concurrent pain: duloxetine
fatigue: bupropion or fluoxetine

55
Q

drugs for sensory symptoms in MS

A

DOC for chronic pain: carbamazepine
painful dysasthesias: TCAs, carbamazepine, gabapentin, SNRIs, pregabalin

56
Q

drugs for sexual dysfunction in MS

A

sildenafil (Viagra), tadalafil (Cialis), vardenafil (Levitra) in men; lubricants in women

57
Q

alternative/complementary therapy for MS

A

oral cannabis; synthetic THC are probably effective for reducing patient-reported symptoms of spasticity and pain

neurology/psychiatry (22 decks)

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