Multiple Sclerosis

Question 1

Multiple Sclerosis

Answer 1

• inflammatory dz of CNS

- many areas of brain and spinal cord affected by plaques or sclerosed areas

Question 2

MS Pathophys

Answer 2

• demyelination and inflammation leads to
• plaques in brain and spinal cord which leads to
• neurologic sxs reflective of affected areas

Question 3

What are the 4 MS classifications?

Answer 3

• relapsing/remitting (discrete attacks then recovery)
• primary progressive (steady decline)
• secondary progressive (starts RRMS then decline)
• progressive relapsing (overlaps PPMS and SPMS)

Question 4

MS Treatment Goals

Answer 4

• decrease severity, intensity and duration of exacerbations
• enhance exacerbation recovery
• prevent relapse and onset of progressive dz
• stop or reverse progressive MS
• provide symptomatic relief

Question 5

How are moderate and severe acute exacerbations treated?

Answer 5

corticosteroid

Question 6

Corticosteroids MOA in PD

Answer 6

• unclear

- may help preserve myelin and maintain BBB integrity

Question 7

Why should corticosteroid use be reserved for PD exacerbations?

Answer 7

-effects are transient and tend to diminish w/ repeated use

Question 8

Plasma Exchange

Answer 8

-tx option for pts w/ very severe attacks that do not respond to aggressive corticosteroid treatment

Question 9

Interferons MOA

Answer 9

• alter expression and response to surface antigens
• can augment suppressor cell function
• can suppress T-cell proliferation
• may decrease BBB permeability

Question 10

Name a couple interferon meds for MS.

Answer 10

• beta 1a: Avonex and Rebif

- beta 1b: Betaseron and Extavia

Question 11

Efficacy of Interferons

Answer 11

• decrease frequency of exacerbations and delay disability

- early tx with interferon assoc with significant reduction in risk of MS progression

Question 12

What is a contraindication of all interferon meds?

Answer 12

pregnancy and lactation

Question 13

What are the most common adverse effects of interferon meds?

Answer 13

-HA, flu-like sxs, myalgia, injection site rxn

Question 14

Interferon Monitoring

Answer 14

• EDSS: kurtzke expanded disability status scale 0-10

- baseline CBC, plt, LFTs at 1 month then q3 months x1 year, then q6 months

Question 15

Glatiramer/Copaxone Indication

Answer 15

relapsing remitting

Question 16

Glatiramer/Copaxone Efficacy

Answer 16

decreases relapses and postpones relapses

Question 17

Glatiramer/Copaxone AEs

Answer 17

• vasodilation
• arthralgia
• chest pain
• injection site reaction

Question 18

Fingolimond/Gilenya Indication

Answer 18

• relapsing remitting

- progressive relapsing

Question 19

Fingolimond/Gilenya Efficacy

Answer 19

modestly better than avonex (interferon) at preventing relapse

Question 20

Fingolimond/Gilenya AEs

Answer 20

• HA, increased LFTs
• decrease HR, heart block
• macular edema, bronchitis, pneumonia

-avoid in pts w/ recent MI, angina, stroke, TIA, severe HF

Question 21

What is unique about Fingolimond/Gilenya?

Answer 21

first ORAL disease modifying therapy for MS

Question 22

Teriflunomide/Aubagio Indication

Answer 22

relapsing forms of MS

Question 23

Teriflunomide/Aubagio AEs

Answer 23

• N/D
• hair loss
• black box warning for hepatotoxicity
• increased infx risk
• teratogenic

Question 24

Teriflunomide/Aubagio Monitoring

Answer 24

-LFTs baseline, qmonth x6 months, then periodically

Question 25

Dimethyl Fumarate/Tecfidera Indication

Answer 25

relapsing forms of MS

Question 26

Dimethyl Fumarate/Tecfidera AEs

Answer 26

- flushing - N/D - decreased WBC - rare progressive multifocal leukoencephalopathy

Question 27

Dimethyl Fumarate/Tecfidera Monitoring

Answer 27

-WBC baseline, q 3-6 months, then periodically

Question 28

Mitoxantrone/Novantrone Indications

Answer 28

approved to decrease frequency of relapses and/or neurologic disability in adults w/ SPMS, PRMS or worsening RRMS

Question 29

Mitoxantrone/Novantrone AEs

Answer 29

- decreased WBC and platelets, anemia - increased LFTs - decreased LVEF, HF - UTIs, N/V, mucositis - black box warning cardiotoxicity, acute myelogenous leukemia

Question 30

Which pts should use Mitoxantrone/Novantrone?

Answer 30

-reserved for pts with worsening dz because of cardiotoxicity AEs

Question 31

Natalizumab/Tysabri Indication

Answer 31

-monotherapy for relapsing forms of MS in pts who have documented inadequate response or intolerance to traditional MS therapies

Question 32

Why should Natalizumab/Tysabri only be used as monotherapy?

Answer 32

fatalities reported w/ combination therapy

Question 33

Natalizumab/Tysabri AEs

Answer 33

- rare progressive multifocal leukoencephalopathy - pts followed in ongoing safety registry - hepatotoxicity

Question 34

Which pts should use Natalizumab/Tysabri?

Answer 34

reserved for pts who can't tolerate or don't respond to other therapies (due to risk of PML and hepatotoxicity)

Question 35

How long should therapy be continued?

Answer 35

- continue indefinitely | - do not stop treatment during evaluation for continuing treatment

Question 36

What medication should be prescribed as soon as possible following a definite MS diagnosis?

Answer 36

- interferon beta medication (Avonex, Rebif) | - or glatiramer acetate

Question 37

Who should not use any of the MS medications?

Answer 37

pregnant or nursing mothers

Question 38

Which drugs are considered first line disease modifying therapy for MS?

Answer 38

- interferon beta | - glatiramer/copaxone

Question 39

Dalfampridine/Ampyra Efficacy

Answer 39

- increased walking speed in 35-45% of MS pts | - improved walking speed = improved ambulation

Question 40

Dalfampridine/Ampyra AEs

Answer 40

- back pain, dizziness, insomnia, fatigue - nausea, balance disorder, UTI, falls, HA - rare seizure

Question 41

Pt Education for MS

Answer 41

- educate about MS - community support - tx: injection techniques, adverse effects, symptomatic management