Lecture 40-41 - Pharmacotherapy of Multiple Sclerosis Flashcards
Dissemination in Time (DIT)
Time between evidence of new lesions in subsequent MRIs (30 days) – damage that has happened more than once
Dissemination in Space (DIS)
Need for > 1 T2 lesion appearing in at least two of four MS‐typical CNS regions (cortical, periventricular, infratentorial, spinal cord) – damage that is in more than one place
Diagnosis of MS requires
having at least 2 demyelination‐related episodes separated by time and space; new criteria allows for use of MRI and CSF testing at the first event for diagnosis
Clinically Isolated Syndrome (CIS):
descriptor of a first demyelinating event involving the optic nerve, cerebrum, cerebellum, brainstem or spinal cord
most will develop MS within 20 years
Relapsing Remitting MS (RRMS):
most common type (80 – 90% of diagnoses); consists of relapses with partial or complete remission between relapses; most will become progressive type over time
Secondary Progressive MS (SPMS):
~ 80% of RRMS patients will progress to SPMS, consisting of fewer relapses with continuing disability
Primary Progressive MS (PPMS):
10 – 15% of patients – progressive form from onset with minor
improvements or periods of stability; more common in patients diagnosed in later years (> 50 years of age)
Progressive Relapsing MS (PRMS):
least common form (~ 5% of diagnoses); steadily worsening disease from onset with later, clear, acute relapses; may be some recovery from acute attacks, but no remission between relapses
EDSS is used to
assess effectiveness of drug therapy
0: normal neurological function
1: no disability with only minimal signs
2: minimal disability
3: moderate disability
4: relatively severe disability
5: disability affects full daily activities (cane)
6: assistance required to walk and work (walker)
7: essentially restricted to a wheelchair
8: restricted to bed or wheelchair
9: bedridden inable to communicate effectively or eat/swallow
10: death
Treatment of acute attacks
High‐dose corticosteroid treatment is the first
choice; oral or intravenous treatment based on setting (inpatient vs. outpatient)
Methylprednisolone 500mg – 1000mg IV daily for 3 to 7 days, with or without an oral taper over 1 – 3 weeks
If outpatient: oral prednisone 1250mg every other day x 5 doses without need for taper
Oral medications
Dimethyl fumurate (Tecfidera®)
Diroximel fumarate (Vumerity®)
Fingolimod (Gilenya®, Tascenso ODT®)
Ozanimod (Zeposia®)
Ponesimod (Ponvory®)
Siponimod (Mayzent®)
Teriflunomide (Aubagio®)
Injectable medications
Interferon beta‐1a (Avonex®, Rebif®)
Peginterferon beta‐1a (Plegridy®)
Interferon beta‐1b (Betaseron®, Extavia®)
Glatiramer acetate (Copaxone®)
Infusion medications
Alemtuzumab (Lemtrada®)
Natalizumab (Tysabri®)
Ocrelizumab (Ocrevus®) - only one indicated for PPMS
Progressive multifocal leukoencephalopathy
Rare, serious adverse event caused by reactivation of dormant JCV; decreases functioning of person’s immune system
Causes the cells that produce myelin to break down, can look similar to a MS relapse
Patients must be tested for JCV antibodies (prior to getting med for MS)
Vaccines
Inactivated vaccines are preferred for people with multiple sclerosis
Live, attenuated vaccines are not recommended because the ability to cause the disease is weakened, but not eliminated
Alemtuzumab - no live virus vaccines
Varicella vaccine should be considered by people with MS who have never had chicken pox, especially if they may start a MS medication that suppresses cell‐ mediated immunity (fingolimod, alemtuzumab)
