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Multiple Sclerosis

  1. what is a clinically isolated syndrome
    the first attack or onset of Sx
  2. Sx of CIS
    • optic neuritis
    • spinal transverse myelitis
    • brainstem and cerebellar lesions
  3. what is uthoffs phenomenon
    • overlap in the nerve terminal
    • reversible exacerbation
  4. unfavorable prognostic factors of MS
    • > 40 yrs
    • male
    • motor or cerebellar sx
    • progressive
    • high attack frequency
  5. most common subtype of MS
    relapse-remitting
  6. what are pts with RRMS initially responsive to
    immunosuppression
  7. what is RRMS
    • last at least 24 hrs
    • separated from new sx by at least 30 days
    • followed by remissions
  8. secondary progressive MS
    progressive phases with or without relapses
  9. how does SPMS respond to immunosuppression
    less responsive than RRMS
  10. what is Progressive-relapsing MS (PRMS)
    slow onset of progressive phase with superimposed attacks/relapses
  11. what is primary progressive MS (PPMS)
    the onset of progressive neurological dysfunction without attacks/relapses or remission
  12. PPMS response to immunotherapy
    little to no response
  13. which disease state is the least likely to have new MRI inflammatory lesions
    PPMS
  14. what does the diagnosis of MS require
    • 1. clinical signs and sx
    • 2. elimination of more likely dx (differential)
    • 3.s demonstration of dissemination of lesions in space and time
  15. what are the white areas on an MRI scan
    lesions
  16. agents used to manage balance
    • meclizine
    • prochlorperazine
    • promethazine
  17. agents used for spasticity
    • baclofen
    • tizanidine
    • dantrolene
    • diazepam
    • clonazepam
    • gabapentin
  18. agents used to manage fatigue
    • amantadine
    • modafanil
    • stimulants
    • SSRIs
  19. agents used to treat incontinence (bladder)
    • desmopressin
    • oxybutynin
    • tolterodine
    • TCAs
  20. agents to manage incontinence (bowel)
    • dicyclomine
    • laxatives
    • j
  21. agents used to treat pain
    • carbamazepine
    • gabapentin
    • pregabalin
    • duloxetine
  22. agents used to manage depression
    • SSRI/SNRI
    • TCA
  23. target of current treatments for RRMS
    inflammation

    early tx of CIS w immunotherapy may delay conversion to MS
  24. which types of acute exacerbations need to be treated
    severe exacerbations

    mild exacerbations do not significantly impact a persons activities
  25. DOC for acute exacerbations
    methylprednisolone (Medrol)
  26. high doses of Medrol have been shown to shorten duration and repeat attacks of
    optic neuritis
  27. low doses of Medrol have been used for
    milder MS attacks
  28. pulse doses of Medrol given once a month have been helpful in treating
    active MS
  29. main ADRs for corticosteroids
    • Insomnia
    • hyperglycemia
    • hypertension
    • fluid retention
    • wt gain
  30. acute monitoring for corticosteroids
    • blood glucose
    • INR
    • glaucoma
    • epilepsy
  31. drug regimen for pts with acute exacerbations

























    drug therapy for a pt with +
    • IV Medrol 500mg - 1g for 3-7 days
    • PO prednisone 500 - 1.25g for 3-7 days or 1 to 2 weeks
  32. DMT is not effective in
    highly active inflm and progressive MS
  33. 1st line DMT
    • betaseron
    • avonex
    • rebif
    • glatiramer acetate (copaxone)
  34. betaseron IND and dosing
    • RRMS and SPMS relapses
    • 62.5 mcg SC qod; increase q 2 wks to 250 mcg
  35. avonex IND and dosing
    • RRMS or CIS with active MRI lesion
    • 30 mcg IM q 1 wk
  36. rebif IND and dosing
    • RRMS only
    • 22-44 mcg SC 3 x per wk (separate by at least 48 hr)
  37. glatiramer acetate IND and dosing
    • RRMS + CIS
    • 20mg SC qd
  38. ADRs of INF agents
    • injection site rxn
    • flu-like sx
    • depression
    • myelosuppression
    • hepatotoxicity
    • SOB
    • tachycardia
    • seizures
    • HA
  39. INF ADR mgmt
    • rotate inj site
    • prednisone PO 10 - 30mg
    • HA- triptans, NSAIDS
  40. INF monitoring
    • CBC/platelets
    • LFTs
  41. how often do you monitor pt on INF therapy
    • baseline
    • q 3mths for 1 yr
    • q 6mths
  42. INF-B injection sites
    thighs or buttocks
  43. copaxone injection site
    • back of upper arm
    • within 2 inches of naval
    • area on side above hip
    • front of leg at least 2 inches above knee
    • 2 inches below groin
  44. INF/glatiramer counseling
    • improve disease progression but not symptoms
    • rotate inj site
    • use aseptic technique
    • warm med to body temp before administration
    • place ice on site of inj before and after
    • administer topical corticosteroids HC cream
    • take APAP or NSAID before and at reg interv for the next 24 hrs
    • educate pt that these symptoms will lessen with use after 3-6 mths of therapy
  45. INF-B SC vs IM efficacy
    increased efficacy seen with increased dosing frequency
  46. oral DMTs
    • teriflunomide (aubagio)
    • dimethyl fumarate (Tecfidera)
    • fingolimod (gilenya)
  47. indication for oral DMTs
    RRMS
  48. teriflunomide black box warning
    • hepatotoxicity (increase LFT)
    • fetal death/malformations
  49. when should fingolimod first be administered
    in the MD office with monitoring up to 6 hrs
  50. signs and sx to educate pt on fingolimod
    • hepatic failure
    • macular edema
    • infection
  51. how long till full effect of fingolimod
    can be months due to t1/2
  52. 2nd line DMTs
    • mitoxantrone (novantrone)
    • natalizumab (tysabri)
  53. how are 2nd line DMTs given
    IV
  54. max lifetime dose of mitoxantrone
    140mg/m2
  55. AE of tysabri
    • PML- stop natalizumab
    • JC viral infection-- demylelination increased risk after 2 yrs
  56. natalizumab counseling
    • educate on signs and sx of PML
    • -stop therapy immediately if sx arise
    • educate pt about touch program
    • -prescriber and pt must be enrolled along with pharmacies and infusion centers
Author
alvo2234
ID
214746
Card Set
Multiple Sclerosis
Description
PT I exam III
Updated

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