Multiple sclerosis Flashcards
What is multiple sclerosis?
Multiple sclerosis is a chronic cell-mediated autoimmune disorder characterised by demyelination in the central nervous system.
What is the epidemiology of multiple sclerosis?
It is 3 times more common in women, most commonly diagnosed in people aged 20-40 years, and much more common at higher latitudes (5 times more common than in tropics).
What is the genetic concordance for multiple sclerosis?
Monozygotic twin concordance is 30%, while dizygotic twin concordance is 2%.
What are the subtypes of multiple sclerosis?
A variety of subtypes have been identified, including relapsing-remitting disease, secondary progressive disease, and primary progressive disease.
What is relapsing-remitting disease?
It is the most common form, accounting for around 85% of patients, characterised by acute attacks followed by periods of remission.
What is secondary progressive disease?
It describes relapsing-remitting patients who have deteriorated and developed neurological signs and symptoms between relapses.
Around 65% of patients with relapsing-remitting disease go on to develop secondary progressive disease within 15 years of diagnosis; gait and bladder disorders are generally seen.
What is primary progressive disease?
It accounts for 10% of patients and is characterised by progressive deterioration from onset, more common in older people.
What is a common non-specific feature of multiple sclerosis?
Around 75% of patients have significant lethargy.
What is required for the diagnosis of multiple sclerosis?
Two or more relapses and either objective clinical evidence of two or more lesions or one lesion with reasonable historical evidence of a previous relapse.
What is a common presenting visual feature of multiple sclerosis?
Optic neuritis.
What phenomenon is characterized by worsening vision following a rise in body temperature?
Uhthoff’s phenomenon.
What are common sensory features of multiple sclerosis?
Pins/needles, numbness, trigeminal neuralgia, and Lhermitte’s syndrome.
What is Lhermitte’s syndrome?
Paraesthesiae in limbs on neck flexion.
What is the most common motor feature seen in multiple sclerosis?
Spastic weakness, most commonly seen in the legs.
What cerebellar feature is more often seen during an acute relapse?
Ataxia.
What are some other features of multiple sclerosis?
Urinary incontinence, sexual dysfunction, and intellectual deterioration.
What is required for the diagnosis of multiple sclerosis?
Demonstration of lesions disseminated in time and space.
What MRI findings are indicative of multiple sclerosis?
High signal T2 lesions, periventricular plaques, and Dawson fingers.
What are Dawson fingers in MRI?
Hyperintense lesions perpendicular to the corpus callosum, often seen on FLAIR images.
What CSF findings are associated with multiple sclerosis?
Oligoclonal bands (and not in serum) and increased intrathecal synthesis of IgG.
What is a characteristic of visual evoked potentials in multiple sclerosis?
Delayed, but well preserved waveform.
What is the focus of treatment in multiple sclerosis?
Treatment in multiple sclerosis is focused on reducing the frequency and duration of relapses. There is no cure.
What is the treatment for an acute relapse in multiple sclerosis?
High-dose steroids (e.g. oral or IV methylprednisolone) may be given for 5 days to shorten the length of an acute relapse.
Steroids shorten the duration of a relapse and do not alter the degree of recovery.
What are the indications for disease-modifying drugs in multiple sclerosis?
Typical indications include:
1. Relapsing-remitting disease + 2 relapses in past 2 years + able to walk 100m unaided.
2. Secondary progressive disease + 2 relapses in past 2 years + able to walk 10m (aided or unaided).
What is natalizumab?
Natalizumab is a recombinant monoclonal antibody that antagonises alpha-4 beta-1-integrin found on the surface of leucocytes, inhibiting their migration across the blood-brain barrier.
It is often used first-line and is considered to have the strongest evidence base for preventing relapse.
What is ocrelizumab?
Ocrelizumab is a humanized anti-CD20 monoclonal antibody, considered a high-efficacy drug often used first-line.
It is administered intravenously.
What is fingolimod?
Fingolimod is a sphingosine 1-phosphate (S1P) receptor modulator that prevents lymphocytes from leaving lymph nodes.
Oral formulations are available.
What is beta-interferon?
Beta-interferon is not considered to be as effective as alternative disease-modifying drugs and is given subcutaneously/intramuscularly.
What is glatiramer acetate?
Glatiramer acetate is an immunomodulating drug that acts as an ‘immune decoy’ and is given subcutaneously.
It is considered an ‘older drug’ with less effectiveness compared to monoclonal antibodies and S1P receptor modulators.
What is a recommended treatment for fatigue in multiple sclerosis?
Once other problems (e.g. anaemia, thyroid or depression) have been excluded, NICE recommends a trial of amantadine. Other options include mindfulness training and CBT.
What are the first-line treatments for spasticity in multiple sclerosis?
Baclofen and gabapentin are first-line treatments. Other options include diazepam, dantrolene, and tizanidine.
Physiotherapy is also important.
What is the approach to bladder dysfunction in multiple sclerosis?
Guidelines stress the importance of getting an ultrasound first to assess bladder emptying. Anticholinergics may worsen symptoms in some patients.
If significant residual volume → intermittent self-catheterisation; if no significant residual volume → anticholinergics may improve urinary frequency.
What is the first-line treatment for oscillopsia in multiple sclerosis?
Gabapentin is the first-line treatment for oscillopsia.
