Multiple Sclerosis Flashcards
(79 cards)
1
Q
What is the effect of vitamin D in multiple sclerosis?
A
increased vitamin D may decrease disease activity
2
Q
What are risk factors of MS?
A
- smoking
- women
- Northern European descent living above 40 degrees latitude
- 1st degree relative with MS
3
Q
What is the effect of pregnancy in multiple sclerosis?
A
pregnancy is protective against relapses
4
Q
What is required for MS diagnosis?
A
2 documented exacerbations & 2 distinct MRI lesions separated by time and space
5
Q
What is clinically isolated syndrome (CIS)?
A
- the first episode of neuro symptoms lasting greater than 24 h
- 1 attack, 1 lesion
- may or may not become MS
6
Q
What is relapsing remitting MS (RRMS)?
A
- most common MS
- worsening or onset of new symptoms for greater than 48 hrs WITHOUT fever
- contrasted by symptom free periods where symptoms partially or completely disappear
7
Q
What is secondary progressive MS (SPMS)?
A
starts as RRMS and turns to progressive
8
Q
What is primary progressive MS (PPMS)?
A
- steady decline without relapses
- meds are generally not effective
9
Q
What is progressive relapsing MS (PRMS)?
A
- steady progression with periods of exacerbation
- can only treat relapses will still progress
10
Q
What are the 2 options for acute MS relapse treatment?
A
- methylprednisolone IV x 3-5 days (+/- PO prednisone taper)
AND H2RA/PPI for ulcer prophylaxis - acthar gel IM or subQ for 2-3 weeks
11
Q
What is PML (progressive multifocal leukoencephalopathy)?
A
fatal viral opportunistic infection caused by activation of latent John Cunningham polyomavrius and causes demyelinating diseases (like MS)
12
Q
What are risk factors for PML?
A
- testing + for JCV antibodies
- prior use of immunosuppressive meds
- using natalizumab for > 2 years
13
Q
What are the interferon beta-1a agents that are used for MS?
A
- Avonex
- Rebif
- Plegridy (pegylated)
14
Q
What is the indication for all interferon beta agents used in MS?
A
CIS, RRMS, active SPMS
15
Q
What is the class ADR for interferon beta agents used in MS? (5)
A
- Flu like symptoms (pretreat w/ NSAID/APAP, improves overtime)
- injection site run
- depression
- abdominal pain
- increased LFTs
16
Q
What is the interferon beta-1b agent used for MS?
A
Betaseron/Extavia
17
Q
Which interferon beta is administered IM weekly in MS?
A
Avonex (beta-1a)
18
Q
Which interferon beta is administered subQ TIW in MS?
A
Rebif (beta-1a)
19
Q
Which interferon beta is administered subQ every 2 weeks in MS?
A
Plegridy (pegylated beta-1a)
20
Q
Which interferon beta is administered subQ every other day in MS?
A
Betaseron/Extavia (beta-1b)
21
Q
What is the indication for Glatiramer acetate (Copaxone, Glatopabiosimilar) in MS?
A
CIS, RRMS, active SPMS
22
Q
How is Glatiramer acetate (Copaxone, Glatopabiosimilar) administered in MS?
A
subQ
either 20 mg daily or 40 mg TIW
23
Q
What MS agent prevents transmigration of leukocytes across the endothelium via antagonizing alpha 4 integrin on VLA 4 of leukocytes?
A
Natalizumab (Tysabri, Tyrukobiosimilar)
24
Q
Which MS agent has a BBW for PML & requires enrollment into the TOUCH program?
A
Natalizumab (Tysabri, Tyrukobiosimilar)
25
What is the indication for Natalizumab (Tysabri, Tyruko*biosimilar*) in MS?
CIS, RRMS, active SPMS
26
How is Natalizumab (Tysabri, Tyruko*biosimilar*) administed in MS?
IV infusion q4w
27
What MS agent targets CD52 on immune cells and reduces the number of circulating T cells?
Alemtuzumab (Lemtrada)
28
What is the indication for Alemtuzumab (Lemtrada) in MS?
RRMS or active SPMS
WITH inadequate response to 2 or more meds
29
What are 2 common ADR in patients on Alemtuzumab (Lemtrada) for MS?
1. development of a thyroid disorder
2. rash
30
What are the BBWs for Alemtuzumab (Lemtrada) in MS therapy?
1. immune thrombocytopenia
2. infusion reaction (pre med w/ steroids, 2 hour post injury monitoring)
3. malignancy
31
How is Alemtuzumab (Lemtrada) administered in MS?
IV infusion
12 mg over 4 hours x 5 days
repeat 3 day course at 1 year
can do another 3 day course after another 12 mo
32
What MS agents bind CD20 on B cells & depletes them from circulation?
1. Ocrelizumab (Ocrevus)
2. Ublituximab (Biumvi)
3. Ofantunumab (Kesimpta)
33
What are the general indications across all CD20 binding mAbs used for MS?
Which CD20 agent ALSO has indication for PPMS???
CIS, RRMS, active SPMS
Ocrelizumab (Ocrevus)
34
Which CD20 mAbs used in MS require the dose to be split for the 1st IV infusion and then given every 6 mo thereafter?
1. Ocrelizumab (Ocrevus)
2. Ublituximab (Biumvi)
35
What are common ADR of the CD20 mAbs used for MS?
infusion reactions
UTI, URI
HA, nausea
PML
36
Which CD20 mAb used for MS needs to have the 1st injection done under medical supervision?
Ofantunumab (Kesimpta)
37
How is Ofantunumab (Kesimpta) administered in MS?
subQ
QW x 3 doses THEN QM
38
What chemotherapy agents are used in MS?
1. Mitoxantrone (Novantrone)
2. Mavenclad (cladribine, 2-chloro deoxyadenosine)
39
What is the indication for Mitoxantrone (Novantrone) in MS?
*PRMS*, SPMS & RRMS
reserved for rapidly advancing refractory MS
40
How is Mitoxantrone (Novantrone) administered in MS?
IV based on BSA q3mo
**MAX cumulative lifetime dose of 100 mg/m^2**
41
What are the BBWs for Mitoxantrone (Novantrone)?
1. cardiotoxicity
2. bone marrow suppression
42
What is the indication for Mavenclad (cladribine, 2-chloro deoxyadenosine) in MS?
RRMS & active SPMS
WITH failure or CI to other therapies
43
How is Mavenclad (cladribine, 2-chloro deoxyadenosine) administered in MS?
PO tab (separate from other meds by 3 hours)
given as 3.5 mg/kg over a 2 year treatment course (half of total dose each year)
split into 2 cycles/year that are 4-5 days and 23-37 days apart
2nd year has to be at least 43 weeks from previous cycles
can repeat another 2 year course; minimum of 2 years later
44
What is required before the first course of Mavenclad (cladribine, 2-chloro deoxyadenosine) for MS?
What about for subsequent courses?
lymphocytes WNL
lymphocytes >/= 800 cells/mm^3
45
What are the BBWs for Mavenclad (cladribine, 2-chloro deoxyadenosine)?
1. malignancy
2. teratogenicity (contraceptive during & 6 mo after)
46
How long is contraception needed after Mavenclad (cladribine, 2-chloro deoxyadenosine) therapy is complete?
What is an additional pearl regarding hormonal contraceptives & Mavenclad?
6 months
Mavenclad decreased the effect of oral contraceptives
47
What are MS agents that act on sphingosine-1-phosphate (S1P) recep and decreases overall number of lymphocytes in circulation?
1. Fingolimod (Gilenya - PO, Tascenso*biosimilar* - ODT)
2. Siponimod (Mayzent)
3. Ozanimod (Zeposia)
4. Ponesimod (Ponvory)
48
What are the indications of S1P drugs for MS?
CIS, RRMS, active SPMS
49
What is the frequency of dosing for all S1P drugs used for MS?
QD!
50
Which S1P used in MS ALWAYS required 6 hour post dose BP monitoring?
Fingolimod (Gilenya - PO, Tascenso*biosimilar* - ODT)
51
Which S1P's require first dose monitoring ONLY if the patient has pre-existing cardiac conditions?
How many hours is needed for each?
1. Siponimod (Mayzent) -> 6 hours
2. Ponesimod (Ponvory -> 4 hours
52
In what circumstance should 1st dose monitoring continue overnight for any of the S1Ps used for MS that require 1st dose monitoring?
if pt is high risk
- prolonged QT
- drugs w/ Torsades risk or that affect HR
53
What S1P drug used for MS has dosing dependent on CYP2C9 genotyping?
What CYP2C9 genotype is contraindicated?
Siponimod (Mayzent)
*3/*3
54
What MS agents are associated with rebound syndrome (severe increase in disability) upon D/C?
S1P drugs
1. Fingolimod (Gilenya - PO, Tascenso*biosimilar* - ODT)
2. Siponimod (Mayzent)
3. Ozanimod (Zeposia)
4. Ponesimod (Ponvory)
55
When does 1st dose monitoring need to be repeated in patients on Fingolimod (Gilenya - PO, Tascensobiosimilar - ODT) for MS?
1 days missed in 1st 2 weeks
7 days missed in a row in weeks 3-4
14 days missed after 1 mo
56
When does 1st dose monitoring need to be repeated in patients on Siponimod (Mayzent) for MS?
1 day missed in initial regimen
4 days or more missed in maintence
57
When does 1st dose monitoring need to be repeated in patients on Ponesimod (Ponvory) for MS?
4 days or more missed
58
What MS agent produces a cytostatic effect on proliferating B & T cells in the periphery?
Teriflunomide (Aubagio)
59
What is the indication for Teriflunomide (Aubagio) in MS?
CIS, RRMS, active SPMS
60
How is Teriflunomide (Aubagio) administered in MS?
PO QD
food delays abs by 6h but can take w/ food
61
What CI does Teriflunomide (Aubagio) have in MS?
1. pregnancy
2. breastfeeding
62
What BBWs does Teriflunomide (Aubagio) have in MS?
1. hepatotoxicity
2. teratogenicity
63
How long is a contraceptive needed after Fingolimod (Gilenya - PO, Tascensobiosimilar - ODT) therapy for MS is complete?
2 months
64
How long is a contraceptive needed after Siponimod (Mayzent) therapy for MS is complete?
10 days
65
How long is a contraceptive needed after Ozanimod (Zeposia) therapy for MS is complete?
3 months
66
How long is a contraceptive needed after Ponesimod (Ponvory) therapy for MS is complete?
1 week
67
Teriflunomide (Aubagio) has a very long t1/2 of 8mo-2y, what can be done to accelerate it's elimination?
admin....
cholestyramine 4g q8h x 11 days
OR
activated charcoal 50g q12h x 11 days
68
What is the MAX dose of rosuvastatin that can be given to a patient on Teriflunomide (Aubagio)?
10 mg
69
What effect does Teriflunomide (Aubagio) have an INR?
may decrease INR in patients on warfarin (inc risk of clot)
70
What MS agents belong to the fumurate class?
1. Dimethyl Fumarate (Tecfidera)
2. Diroximel Fumarate (Vulmerity)
3. Monomethyl Fumarate (Bafiertam)
71
What is the MOA of fumurates in MS?
induces T helper 2 like cytokines leading to decreased leukocyte migration & is involved in cell response to oxidative stress
72
How are the fumurates dosed in MS?
PO BID
73
Which fumurate needs to have its unopened bottle stored in the fridge?
Monomethyl Fumarate (Bafiertam)
74
Which fumurate requires meals to have a MAX 30 g of fat and 700 calories?
Diroximel Fumarate (Vulmerity)
75
What are fumurates indicated for in MS?
CIS, RRMS, active SPMS
76
What are the common ADR for fumurates in MS?
How can they be minimized?
GI symptoms and flushing
take w/ high fat, hight protein meal
premed w/ non EC ASA 325 mg 30 min before
77
What agent is used for pseudobulbar affect in MS?
Nudexta (dextromethorphan HBr & quinidine sulfate)
78
What agent is used to walking/gait issues in MS?
Ampyra (dalfampridine)
79
When is use of Ampyra (dalfampridine) contraindicated for walking/gait issues in MS?
1. hx of seizures
2. mod-severe renal impairment (CrCl < 50 mL/min)
