Multiple Sclerosis Flashcards
What is the epidemiology of multiple sclerosis?
12% risk if both parents affected
Risk increases as distance from equator increases
More common in women = presents usually in 30s
What is multiple sclerosis?
Inflammatory demyelinating disorder = myelin sheath is first area affected, plaques disseminated in time and place
What are the different types of multiple sclerosis?
Relapsing and remitting multiple sclerosis
Secondary progressive multiple sclerosis
Progressive relapsing multiple sclerosis
Primary progressive multiple sclerosis
What are some features of relapsing remitting MS?
Optic or sensory symptoms = flares up then goes away, most common type
What are some features of secondary progressive MS?
Develops from relapsing remitting MS = symptoms get progressively worse
What are some features of progressive relapsing MS?
Rarest type = progression occurs quickly from symptom onset
What are some features of primary progressive MS?
Occurs in about 10% of patients = never experience any kind of relapse
What are some symptoms of multiple sclerosis?
Pyramidal dysfunction and sensory symptoms
Optic neuritis and lower UT dysfunction
Cerebellar and brainstem features
Cognitive impairment
What are some features of pyramidal dysfunction?
Weakness, increased tone, spasticity
What areas of the body are commonly affected by weakness in multiple sclerosis?
Extensors of arms and flexors of legs
What are some features of optic neuritis?
Painful vision loss = occurs over 1-2 weeks, most improve with time, RAPD
What are some symptoms of cerebellar dysfunction?
Dysarthia, ataxia, nystagmus, intention tremor
What is internuclear ophthalmoplegia?
Disturbance of binocular vision due to defect in medial longitudinal fasciculus = failure of abduction, diplopia, nystagmus in abducting eye, lag
How is fatigue treated?
Amantidine, modafinil if sleepy, hypertonic oxygen
What is the diagnostic criteria for multiple sclerosis?
At least two episodes suggestive of demyelination = dissemination in time and place, alternative diagnosis excluded
What investigations can be done for multiple sclerosis?
MRI, CSF, neurophysiology, blood tests
What are the differentials of multiple sclerosis?
Vasculitis, granulomatous disorder, vascular disease, structural lesion, infection, metabolic disorder
What blood tests are done for multiple sclerosis?
Done to exclude differentials = PV, FBC, CRP, renal/liver/bone profile, auto-antibody screen, borelia/HIV/syphilis serology, B12, folate, vitamin D
How good is a lumbar puncture in detecting multiple sclerosis?
Abnormal in 90+% of patients = oligoclonal bands in CSF but not in serum
What is the management of acute multiple sclerosis?
Mild = symptomatic treatment, may do nothing Moderate = methylprednisolone for 5 days Severe = IV steroids
How is pyramidal dysfunction treated?
Anti-spasmodics and physio
How is spasticity treated?
Baclofen or tizanidine, physio
What are some agents used for symptomatic management in multiple sclerosis?
Anti-convulsants, tricyclics, tens machine, acupuncture, lignocaine if severe pain
What are the first line agents for disease modifying therapy in multiple sclerosis?
For relapsing remitting MS with moderate symptoms = tecfedira/aubagio, interferon beta, glitiramer acetate
What are the second line agents for disease modifying therapy in multiple sclerosis?
For patients who haven’t improved on first line or have severe symptoms = tysabri/ocrevus/lemtrada (monoclonal antibodies), fingolimod, cladrabine
What are the third line agents for disease modifying therapy in multiple sclerosis?
Mitoxantrone, HSCT (stem cell transplant)
What are some features of tecfedira?
Oral 1st line agent = 44% reduction in relapse rate
What are some features of interferon and glitiramer acetate?
Injectable = decrease relapse by 1/3 and severity of relapse by 50%
What are some features of fingolimod/cadrabine?
Oral 2nd line agents = >50% reduction in relapse rate
Toxic = need to wear cardiac monitor for a day before prescribing and lowers WCC
What are some examples of monoclonal antibodies?
Anti CD20 = ocrelizumab, rituximab
Anti CD50 = alemtuzemab
Anti-integrin = natilizumab
When are monoclonal antibodies indicated for treating multiple sclerosis?
Highly active relapsing remitting multiple sclerosis
