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PSYCH Therapeutics > Multiple Sclerosis > Flashcards

Multiple Sclerosis Flashcards

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1
Q

Risk Factors for MS :

  1. Sex
  2. Age?
  3. Other autoimmune diagnoses such as ?
  4. __ hx
    5.S
  5. Excess ?
  6. Race such as
  7. Environmental such as ? (4)
A
  1. Women have a higher chance
  2. Ages 20-50
  3. Thyroid, type 1 diabetes, IBD
  4. Family
  5. Smoking
  6. excess body weight
  7. northern european
  8. Viral infections (MMR, EB virus)
    - Geographic locations
    -Sunlight exposures (Vit D deficiency)
    -Changes in temp/humidity
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2
Q

Main sx’s of MS:
Central, Visual, Speech, throat, MSK, Sensation, bowel, urinary

A

See Chart!

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3
Q

In general, what agents would you use to treat the following :
1. ACute exacerbations
2. Relapsing MS
3. SPMS

  1. Define a relapse
A
  1. Steroids, “plex”
  2. DMT
  3. DMT, STeroids, others
  4. New neurological sx or sx’s or the worsening of an OLD sx, which lasts at least 24 hrs, and is NOT DUE to another cause such as fever, infection or heat.
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4
Q

DMT’s - General Considerations
1. Type of __ and __
2. __ plans
3. Vaccination status because?
4. AE risk profile
5. Patient ___
6. I

A
  1. MS , burden of disease
  2. pregnancy plans
  3. NO LIVE VACCINES ON TX
  4. Preferences
  5. Insurance
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5
Q

What’s PML and what’s it caused by?
What happens when you have PML?

A
  1. Progressive multifocal leukoencephalopathy
    -Opportunistic CNS infection seen usually in immunocomp patients (HIV)
  2. Caused by JC virus
  3. Signif neuropsych and motor dysfunction
    (Visual changes, cog deficits, language probs, seizures)
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6
Q

Lower Effectiveness DMT’s : IFN, Plegridy, Glatiramer Acetate

  1. They’re all SQ except for ?
  2. Plegridy is?
  3. Which ones are self injectable IFN’s?
  4. Dosing varies from ?
  5. All are ___ that are degraded by ___
  6. All should be stored in ?
A
  1. Avonex (IFNBeta -1a) –> it’s IM
  2. SQ AND IM
  3. Rebif, Avonex (IFNBeta-1a)
    - Betaseron and Extavia (IFNBeta-1b)
  4. Daily to every 2 weeks
  5. Proteins, proteolytic enzymes
  6. Fridge
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7
Q

Lower Effectiveness DMTs: Monitoring + Counseling

  1. IFNS can cause new or worsening ?
  2. IFNS can cause ___ post injection
  3. Lab monitoring ?
  4. Glatiramer acetate can cause __ and __
  5. Post injection systemic reaction such as ?
    -How long does it last?
  6. Glatiramer acetate is pregnancy categ ?
  7. Glatiramer is dosed how often?
  8. Rebif (IFNB-1a) dosed?
  9. Avonex (IFNB-1a) dosed?
  10. Betaseron, extavia (IFNB-1B) dosed?
  11. Plegridy (IFNB-1A) dosed?
A
  1. psychiatric sx’s
  2. Flu like rxns
  3. LFTS, CBC every 6m-1 yr
  4. Lipoatrophy and skin necrosis
  5. chest tightness, flushing, SOB, anxiety, 5-15 mins and is self limited, can happen later on in therapy
  6. B (research in animals ok but not humans), DOC for preg
  7. Daily or 3x/week
  8. 3x/week
  9. 1x/week
  10. every other day
  11. every 2 weeks
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8
Q

Oral DMT’s : Teriflunomide (Aubagio)
–> Dose?

  1. BBW for ? (2)
  2. CI’s? (3)
  3. Many ___ and very long ___
  4. Monitoring ? (3)
  5. Counseling for H, H, L, J, P/C
  6. Take ___ or ___ food?
  7. Whats the accelerated elim procedure?
A

Dose : 7 or 14mg once daily
1. Hepatotoxicity (Careful w/concomitant use of hepatotoxic drugs)
- Fetal death and malformations (categ x) –> females of repro age MUST BE USING effetcive contraception

  1. Severe hepatic impairment, pregnancy, concurrent use with Leflunomide
  2. DDI’s, half life
  3. Liver panel (ALT) monthly for 6 months then periodically, CBC w/differential and BP periodically
  4. HA, hair thinning, liver probs, Joint pain, preg/contraception
  5. with or w/o
  6. Cholestyramine 8 grams Q8h x 11 days
    - activated charcoal 50grams q12h x 11 days
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9
Q

ORAL DMTs : Fumarates
1. Has no __ or ___
2. Not recc in ___
3. Minimal ___
4. Whats the dosing freq? Half life?
5. Whats main lab concern?
6. F
7. ___ side effects
8. WHat needs to be monitored? (3)

A
  1. BBB , CI’s
  2. Pregnancy
  3. DDI’s
  4. Twice daily , very short half life
  5. Lymphopenia
  6. FLushing
  7. GI
  8. CBC w/differential , LFTS every 6-12 months, s/sx of PML
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10
Q

Counseling for Fumarates :
1. DMF
2. DRF
3. MMF
4. DO NOT __, __ or __ capsules
5. Most flushing and GI efffects gone in ?
6. What should be taken 30 mins before 1st dose?
7. P and C

Kim see chart for doing

A
  1. Take w or wo food; strongly recc with food, especially HIGH FAT FOOD (peanut butter)
  2. Take w or wo food; AVOID HIGH CALORIE >700 cals, high fat > 30g meals and avoid co admin w/alcohol
  3. take w or wo food
  4. crush, split, open
  5. 4 weeks to 3 months
  6. aspirin 81 mg
  7. Preg and contraception
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11
Q

ORAL DMT’s : S1Ps Overview
1. No ___ but many ___
2. Not recc in ___
3. Dosing freq?
4. Variable ___ but all have them . also variable__
5. Will need baseline ___
6. ___ suppressing
7. Risk of ?
8. What are CI’s? (1)
9. Warnings for?
M,S,I,P,L,P,R,A,S,T,I

A
  1. BBW, CI’s
  2. Pregnancy
  3. Once daily
  4. DDI’s, half life
  5. monitoring
  6. Immune
  7. rebound activity
  8. Mostly cardiac - bradycardia or anything that slows conduction
  9. Macular edema
    * Skin malignancies
    * Infections (herpes zoster)
    * PML
    * Liver injury
    * Posterior Reversible Encephalopathy Syndrome (PRES)
    * Respiratory effects
    * Avoid in pregnancy
    * Severe rebound after stopping
    * Tumefactive MS
    * Increased Blood Pressure
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12
Q

S1P’s : Monitoring at Baseline
1. (8) V, O, C, L, E, F, B, H

  1. For siponimod?
  2. Maintenance monitoring ? (5)
  3. Fingolimod First dose observation ? (3)

S1P’s : COunseling

  1. Food and taking the med?
  2. __ monitoring and expected ___
  3. If missed doses?
  4. Preg/contraception when to advice patient?
A
  1. Varicella zoster immunity, ocular coherence
    tomography (OCT) for macular edema, CBC with
    differential, LFTs, ECG, FEV1 if h/o COPD/asthma,
    blood pressure and heart rate
  2. CYP2C9 genotyping
  3. CBC with differential, LFTs every 6
    months; OCT between 3-4 months then prn;
    dermatologic eval prn, FEV1 prn
  4. Baseline vitals, BP/HR every 6hrs, repeat ECG
  5. Take with or without food
  6. Lab monitoring, abnorms
  7. May have to repeat FDO or re-titration
  8. During tx and AFTER stopping
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13
Q

S1P’s Key Differences :
1. How does the PK vary?
2. DDI’s?
3. Dosing –> Which requires FDO? UNLESS you have ____ for the other S1P’s
4. Whats used for other S1p’s ?

A
  1. Diff absorb, distrib, metab, and elim for all
  2. Different DDI’s and food interactions
  3. Fingolimod , cardiac indications
  4. Dose titration
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14
Q

ORAL DMT’s :Cladribine (Mavenclad)
1. What are BBW’s (2) and CI’s? (5)
2. Not recc in ?

  1. 2 courses with 2 cycles each
  2. Can be ____
  3. When is it typically used?
  4. What needs to be monitored at baseline? (8)
    - Maintenance?
A
  1. Incr risk of malignancy . screen prior to use
    Teratogenicity : should use effective contraception during and 6 months after last tx in men AND women

CI : current malignancy
* Pregnant women and men or women not preventing a pregnancy during use or within 6 months after
* HIV infection
* Active chronic infections
* Breastfeeding on the day of treatment or 10 days after last treatment

  1. pregnancy
  2. immune suppressing
  3. Only after other DMT’s tried /failed
  4. Cancer screening, CBC with differential, HIV, Hepatitis B and C serologies, TB, varicella zoster immunity, MRI within 3 months, LFTs
  • CBC w/differential 2 and 6 months after start of each course and before 2nd course
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15
Q

Cladribine (Mavenclad) : Counseling
1. Administer separate from ?
2. Food?
3. Careful __ with ___
4. Prophylaxis with ___ if ___

A
  1. Other oral meds by 3 hrs
  2. With or without
  3. handling, dry hands
  4. anti herpes medication if lymphocyte count < 200 (Acyclovir 200mg BID)
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16
Q

High Effectiveness IV INFUSIONS AND INJECTABLES : Natalizumab (Tysabri)
q4weeks IV***

  1. BBW and CI’s all related to ___
  2. Uses __ program
  3. Pregnancy?
  4. Dosing ?
  5. No ___
  6. Risk of __ when ___
  7. Biosimilar exists called
  8. BBW for Natalizumab? (1)
  9. Risk factors for developing PML? (3)
  10. Monitor for new signs/sx’s suggestive of PML such as?
  11. May progress from ___ to ___
  12. Check ____ at baseline and q6months
A
  1. PML
  2. REMS
  3. Okay, doesnt cross until 3rd trimester
  4. Monthly
  5. DDI’s
  6. Rebound, stopping
  7. Natalizumab-Sztn (tyruko)
  8. Incr risk of PML
  9. Therapy duration, prior immunosupp use, presence of ANTI-JC virus AB’s
  10. Weakness on one side of body
    * Clumsiness of limbs
    * Vision disturbances
    * Changes in thinking, memory and orientation
    * Confusion
    * Changes in personality
  11. days, weeks
  12. JC virus antibody
17
Q

Natalizumab : Monitoring and COunseling
1. Baseline? (4)
2. Maintenance (3)
3. Counseling on ?(4)

A
  1. JCV Ab index, CBC with differential, LFTs, radiographic signs of PML
  2. JCV Ab index every 6 months, periodic CBC w/ diff, LFTs
  3. Infusion reactions
    * Signs and symptoms of PML
    * Adherence important especially in first 6 months
    * Do not want to go more than 12 weeks between infusions
18
Q

ANTI-CD20 (Ocreliz IV, Ofatumumab SQ, Ublituximab IV) :
1. No __
2. CI”s? (1)
3. Warnings for? (4)
4. Not recc during __ but what options are DOC in pre-conception planning?
5. IV dosing every ____, SQ ___
6. Minimal DDI’s such as?, Immune suppressing
7. NOT ASSOCIATED WITH __
8. Monitoring at baseline of ? (6)
9. Monitoring during TX ? (3)
10. Counseling on ?

A
  1. BBW
  2. Active HepB infection
  3. Infusion rxns, injection site rxns, infections, reductions in immunoglobulins
  4. pregnancy, IV options
  5. 6 months, monthly
  6. Other immunosuppresants
  7. rebound
  8. Hepatitis B serologies, CBC with differential, CMP, B cell count (CD19), immunoglobulins, +/- TB test
  9. Signs/sx’s of infection, immunoglobulins, ocrelizumab breast exams in women !
  10. Infusion rxns (hydration, get a ride home)
    - Injection technique and inject site rxns
    -Incr infection risk
19
Q

ANtI CD20 : Infusion rxns
1. Infusion rxns sx’s : D, R, D, F, H, P, F, H, D, N, T

  1. Premed with ?
  2. Post infuson monitoring for at least ?
  3. Rxns can occur up to ?
  4. TX for infusion rxns :
    -Mild to mod?
    -Severe?
A
  1. Dermatologic (pruritus, rash, urticaria),
    -respiratory (bronchospasm, throat irritation,
    oropharyngeal pain, dyspnea, pharyngeal/laryngeal edema), flushing, hypotension, pyrexia, fatigue,
    headache, dizziness, nausea, tachycardia
  2. Methylpred 100 mg IV, Benadryl 50mg IV, +/- Tylenol 975 mg PO, +/- Famotidine 20mg IV 30mins prior to infusion
  3. 1 hr
  4. 24 hrs post infusion
  5. Reduce infus rate by 50% and maintain for at least 30 mins; resume titration schedule
  • stop infusion, admin supportive tx, after all sx’s resolved, restart infusion at HALF infusion rate the sx’s presented ; resume titration schedule
20
Q

Alemtuzumab (Lemtrada) Overview :

  1. WHAT ARE THE BBW’S? (4)
  2. Uses ___ program
  3. NOt recc during __
  4. How many courses?
  5. CI? (3)
  6. Monitoring at baseline?
    -Maintenance?
  7. Counseling on ? (4)
  8. In which patient group would a stem cell transplant show greatest benefit?
A
  1. Autoimmunity, infusion rxns, stroke,malignancies
  2. REMS
  3. Pregnancy
  4. 2 courses 1 yr apart
  5. HIV, active infection, known hypersensitivity
  6. CBC with differential, CMP, UA, TSH, Thyroid
    peroxidase Antibody, Varicella Zoster Ab, TB, HIV, Urine creatinine/protein ratio, skin exam
  • CBC with differential, SCr, UA monthly and TSH
    quarterly for 48 months after second cycle; skin check annually
  1. ALL BBW AND WARNINGS
    - ALways do lab monitoring
    -Infections
    -Infusion rxns
  2. less disability, more active disease, younger age
21
Q
  1. What are some Non Pharm TX’s?
    E, S, A,M,C,P,O,C,V,S,C

Symptomatic Management : Spasticity
2. What can patients Do?
3. Symptomatic tx that’s not curative?

Symptomatic Management : Fatigue
4. OT ?
5. PT ?
6. ___ regulation
7. ___ interventions
8. Meds?

Symptomatic Management : Decr Mobility
1. What kinds of therapy?
2. Medication?

A
  1. Exercise
    * Stress management
    * Acupuncture
    * Massage
    * Chiropractic therapy
    * Physical therapy
    * Occupational therapy
    * Cognitive rehabilitation
    * Vocational rehabilitation
    * Speech-language pathology
    * Cooling equipment
  2. Daily stretching
  3. Baclofen (Drowsy and muscle weakness), Tizanidine (sedation, dry mouth, decr BP)
    Diazepam (not first line)
  4. Simplify tasks at work/home
  5. Energy saving ways of walking/performing other daily tasks
  6. Sleep
  7. Psych, (stress manage, relaxation training, membership in support group), psychotehrapy
  8. Amantadine HCL, Modafinil, Armodafinil, Ritalin, Addy —> NONE are FDA approved
  9. OT, PT
  10. Ampyra –> Indicated to incr walk speed in MS
    –> CI in Seizures, CrCL < 50
22
Q

Kim : See drug table

A

Drug table

23
Q

Dosing Frequency :
1. Glatiramer Acetate
2. Interferon Beta-1A (rebif)
3. IFN Beta1A (Avonex)
4. IFN BETA 1B (Betaseron/Extavia)
5. Plegridy

A
  1. daily or 3x/week
  2. 3x/week
  3. once weekly
  4. every other day
  5. Every 2 weeks

PSYCH Therapeutics (11 decks)

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