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PHM 701 > Multiple Sclerosis > Flashcards

Multiple Sclerosis Flashcards

1
Q

What type of disease is MS

A

Chronic autoimmnune, inflammatory disease that destroys myelin sheath and impairs the ability to send electrical impulses

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2
Q

What is though to have an effect on MS

A

Higher Vitamin D levels reduce the disease activity in MS patients
The Epstein-Barr virus triggers MS in

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3
Q

How is MS graded on a scale and how is severity determined?

A

On the Kurtzke scale and low is better

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4
Q

What are some symptoms of MS?

A

muscle weakness, blurry vision, bladder problems, cognitive disturbances, sensitivity to heat

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5
Q

How do you diagnose MS?

A

2 documented clinical exacerbation separated by time and space
2 distinct MRI lesion separated by time and space (DIS - on areas known to be affected by MS)

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6
Q

What MRI findings are consistent with MS?

A
  • 4 white matter lesions (>3mm)
  • 3 white matter lesions, 1 periventricular (>6mm)
  • Ovoid lesions perpendicular to ventricles
  • Open ring appearance gadolinium enhancements
  • Corpus callosum lesions
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7
Q

How can you describe CIS

A

1st episode of neuro symptoms lasting 24 hours due to inflammation and demyelination.
Patient may or may not develop MS

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8
Q

What is the most common form of MS?

A

Relapsing Remitting Multiple Sclerosis

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9
Q

How can you described RRMS?

A

Worsening or new onset of symptoms lasting >48 hours contrasted by symptoms free periods (remission)

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10
Q

How can you describe SPMS?

A

Progression of RRMS and is steadily progressing with or without clear-cut relapses

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11
Q

How can you describe PPMS?

A

Rare with a steady decline without clear cut relapses. Meds also aren’t generally effective at this point.

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12
Q

How can you describe PRMS?

A

Rare with steady progression with clear-cut MS exacerbations. Can use steroids but disease will still progress.

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13
Q

What is the treatment for MS?

A

No known cure. Can only treat symptoms

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14
Q

How to treat symptoms of an acute severe attack?

A
  • Methylprednisolone
  • Corticotropin (Acthar gel)
  • H2 blocker/PPI (ulcer prophylaxis)
  • Monitor blood glucose
  • Watch for infection
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15
Q

What are your Original ABCR Injectables

A

Interferon Beta 1a
- Avonix
- Rebif
- Plegridy
Interferon Beta 1b
- Betaseron

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16
Q

What Interferon Beta used for?

A

Relapsing forms of MS: CIS, RRMS, active SPMS

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17
Q

What are the interferon beta side effects?

A
  • Flu like symptoms!!!!!
  • Injection site reaction
  • Depression
  • Myalgia
  • Mayasteria
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18
Q

What is Glatiramer Acetate?

A

may alter T cell activation/differentiation.
Available as Copaxone

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19
Q

What is Copaxone used for?

A

Relapsing forms: CIS, RRMS, actve SPMS

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20
Q

What are the side effects of Copaxone?

A

Injection site reaction
Transient flushing
Chest tightness/pain

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21
Q

What are the monoclonal antibodies used ins MS?

A
  • Natalizumab
  • Alemtuzumab
  • Daclizumab
  • Ocrelizumab
  • Ofatunumab
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22
Q

What does Natalizumab do?

A

Prevent transmigration of leukocytes across endothelium into inflamed parenchymal tissues

*crossing BBB

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23
Q

What is Natalizumab also known as?

A

Tysabri

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24
Q

How is Natalizumab dosed?

A

300 mg IV every 4 weeks

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25
What is Natalizumab used for?
Relapsing forms: CIS, RRMS, active SPMS
26
What is fatal side effect of Natalizumab?
PML - rare, fatal viral infection that is activated by the latent JC virus and is demyelinating
27
What program is Natalizumab under and for what?
TOUCH prescribing program due to PML
28
Who must be registered under the TOUCH program?
Patients Prescribers Infusion centers
29
What are the side effects of Natalizumab?
- Infusion site reaction - Resp Tract Infection - Urinary Tract Infection - Cholelithiasis - Depression - PML
30
What does Alemtuzumab do?
Decrease of T cell circulation
31
What is Alemtuzumab indicated for?
Relapsing forms of MS and reserved for inadequate response to 2 or more medications.
32
What should you do to initiate Alemtuzumab?
Premedicate with corticosteroids for the first 3 days and antiviral prophylaxis (herpes) on the first day till 2 months post alemtuzumab
33
What is the side effect of Alemtuzumab?
- Autoimmnue Thyroid Disorder (GRAVES) - Rash - Neuro problems - Musculoskeletal pain - Shortness of Breath
34
What is Alemtuzumab Black Box Warning?
autoimmnue condition: thrombocytopenia and antiglomerular basement membrane disease Infusion Reaction Malignancy
35
How should you monitor Alemtuzumab?
Monitor TSH levels at baseline and every 3 months Monitor CBC w/ differential, SCr, urinalysis periodically for 48 mos post alemtuzumab Baseline and yearly skin exams ECG prior each treatment
36
Protocol for initiating Alemtuzuamb
Admin in setting with appropriate equipment and personnel (anaphylaxis or infusion reaction) - life threatening Observe for 2 hours
36
How does Ocrelizumab work?
May play a role in immune system mediated damage to brain and spinal cord tissues
37
Are there any medications that can help treat PPMS?
Yes. Ocrelizumab is the first to show results during the ORATORIO trial
37
What does Ocrelizumab do?
It reduces relapse, disease progression and disease activity on MRI in RRMS, SPMS
38
What is Ocrelizumab indicated for?
PPMS, relapsing forms: CIS, RRMS, active SPMS
39
What are your side effects or precautions while on Ocrelizumab?
- decrease in IgG levels (monitor levels for opportunistic infection) - Increase risk in URTI and UTI - Systemic and local injection reaction - PML - Use contraception in reproductive females during and 6 months post
40
What are your immunomodulator drugs?
- Mitoxantrone - Mavenclad
41
How does Mitoxantrone work?
It causes DNA strand breaks and inhibits repair via topoisomerase II. It affects rapidly dividing cells.
42
What is mitoxantrone indicated for?
SPMS, PRMS, worsening RRMS - to reduce neuro disability and relapse frequency - reserve for rapid advancing/refractory
43
What are the side effects of Mitoxantrone?
- Cardiotoxicity - Hepatic dysfunction - Alopecia - Bone marrow suppression (CBC) - Stoma/esophagitis, oral ulceration
44
What is Mavenclad?
Immunomodulator that is a purine nuceloside analog. It is a prodrug and it helps deplete lymphocytes by DNA breakage and repair synthesis shutdown
45
What is Mavenclad indicated for?
RRMS, active SPMS (when response is inadequate)
46
How to dose Mavenclad?
3.5 mg/kg over a 2 year course 1.75 mg/kg/year 4 - 5 consecutive days Available as 10 mg tablets Max daily dose is 20 mg/day
47
What should you do if you miss a dose?
Admin missed dose next day and extend treatment by number of missed doses
48
What is the precaution with taking Mavenclad?
Lymphocyte must be within normal limits before initiating treatment
49
What is the precaution with of Mavenclad administering Mavenclad?
NIOSH says its hazardous so wear gloves during handling, admin, disposal of Mavenclad
50
What is the BBW associated with Mavenclad?
- Malignancies - Teratogenicity
51
What is Mavenclad Contraindicated with?
- Hypersensitivity - Breastfeeding
52
What MS drug requires first dose monitoring?
Fingolomod Siponimod
53
How long does Fingolomod first dose monitoring last?
6 hours -ECG and monitor hourly for bradycardia
54
What are the side effects of Fingolomod?
- Lympho/Leukopenia - URTI - macular edema - Increased BP and Hypertension - Increased LFTs
55
What are your precautions in Fingolomod usage?
Use contraceptives
56
What is Mayzent/Siponomod?
It is an MS drug; S1P receptor modulator that decrease the amount of lymphocytes available to the CNS; blocks from leaving lymph nodes
57
What is Mayzent/Siponomod indicated for?
CIS, RRMS, active SPMS
58
What is the protocol for initiating Mayzent/Siponomod therapy?
CYP2C9 Gentotype testing
59
What genotypes to test for Mayzent/Siponomod?
*1/*1, *1/*2, *2/*2; I: 0.25 - 1.25, M: 2 *1/*3, *2/*3; I: 0.25 - 0.75, M: 1
60
What genotype is contraindicated in Mayzent/Siponomod therapy?
CYP2C9 *3/*3
61
What is the protocol for Mayzent/Siponomod therapy intitation?
First dose monitoring for pre-existing cardiac conditions (6 hours)
62
What are the contraindications of Mayzent/Siponomod?
CYP2C9 *3/*3 MI/TIA/stroke/ADHF (hospitalized)/3rd degree heart block/Class III/IV HF
63
What are the warnings/precautions of Mayzent/Siponomod?
Infections Immunization (test VZV antibodies) PML Macular edema Bradycardia (transient decrease in HR) Atrioventricular conduction delays QT prolongation Cardio disease Respiratory effects Hepatic effects HTN Neurotoxicity Malignancy D/C of therapy (rebound syndrome)
64
What are Mayzent/Siponomod DDIs
Immunosuppresants Bradycardia causing agents AV blocking agents QT prolonging agents 2C/3A4 inducers may decrease conc 2C/3A4 inhibitors may increase concM
65
What are the monitoring parameters for Mayzent/Siponomod?
ECG CBC Hepatic (baseline bilirubin/transaminase) Ophthalmogic exam Respiratory function VZV antibodies Sinus bradycardia 1st/2nd degree AV block h/o MI or HF
66
How does Zeposia/Ozonimod work?
Binds to S1P 1&5 receptors and blocks lymphocytes from emerging from lymph nodes
67
What is contraindicated in Zeposia/Ozonimod therapy?
MI/unstable angina/TIA/ADHF (hospitaliztion), Class III/IV, 2nd or 3rd degree AV block, use of MAOBi
68
What is your diet precaution with Zeposia/Ozonimod?
High tyramine food may cause hypertensive crisis
69
What is Teriflunomide?
It blocks pyrimidine synthesis and decreases the ability of APC's to activate T cells
70
How does Teriflunomide work?
selectively produces a cytostatic effect on proliferating T and B cell lymphocytes in periphery and reduces B cell proliferation
71
What is Teriflunomide indicated for?
For relapsing forms of MS
72
What are the side effects of Teriflunomide?
Nasopharyngitis URTI/UTI Alopecia Sensory disturbances Nasopharyngitis Increased LFTs
73
What are the fumerates used in MS?
Dimethyl Fumerate (Tecfidera) Diroximel Fumerate (Vulmerity) Monomethyl fumerate (Bafiertam)
74
How do the fumerates work?
reduce migration of lymphocytes
75
What are the side effects of a fumerate?
GI side effects (food; due to MMF) Flushing (admin aspirin)
76
What is the difference between the fumerates?
Vulmerity rapidly converts MMF - less GI effects Bafiertam lower dose needed - lower GI effects
77
What are the treatable symptoms of MS?
Spasticity Bladder problems Sensory issues Fatigue/cognitive issue/emotional issues Walking Pseuldobulbar Affect
78
How can you treat spasticity in MS?
Baclofen Dantrolene Benzo (diazepam, clonazepam) Tizanaidine Gabentin, pregabalin, tiagabine Botox Dalfampridine
79
How to treat bladder problems in MS?
Propantheline Oxybutinin Dicyclomine Desmopressin Mirabegron (Mybetriq) ***Antimuscarininc ***Anticholinergic
80
How to treat sensory issues in MS?
Gabapentin Pregabalin Carba/Oxcarbazepine TCAs Lamotrigine Duloxetine
81
How to treat Fatigue/Cognitive/Emotional issue in MS?
Amantadine SSRI/SNRI Modafanil Methylphenidate Dexamphetamine
82
What is pseudobulbar affect?
uncontrollable laughing or crying in MS, AD, ALS patients
83
How can we treat pseudobulbar affect?
Nuedexta
84
What are the contents of Nuedexta?
Dextromethorphan and Quinidine
85
What does Dextromethorphan in PBA in MS?
Inhibit glutamate at NMDA receptor
86
What does Quinidine do in PBA in MS?
Boosts Dextromethorphan (blocks its metabolism)
87
What helps with walking in MS?
Dalfampridine
88
What is Dalfampridine contraindicated in?
It is contraindicared in moderate or severe renal impairment

PHM 701 (8 decks)

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