Multiple Sclerosis
Immune mediated disease that primarilty affects CNS-likely auto immune
Random attacks of inflammation (relapses or exacerbations)
MS etiology
May be result of an abnormal autoimmune response to infection or environmental trigger
Specific trigger unknown
MS pathophysiology
Destroyed areas of myelin in the CNS (primarily white matter)
Can affect cranial nerves (optic)
Axons become irreversibly damaged
Sclerosis in multiple areas
MS epidemiology
90% of pts are b/w 16-60, but can develop anytime.
women>men, but male more aggressive.
Caucasian>hispanics>asians(rare)
Prevalent in temperate zones
Genetic link
500k in US/canada, 2.1+ million worldwide
MS most common s/s
Fatigue. Difficulty walking. B&B problems. Pain/sensory changes. Visual disturbances. Cognitive problems(decreased ST memory). Tremors
Other MS s/s
nystagmus speech difficulty incoordination weakness spasticity muscle spasms sexual dysfunction emaotional instability
T/F: MS is often diagnosed on the initial attack
False
MS diagnosis
Clinical attacks
MRI: Gadolinium used to distinguish new from old lesions
CSF: Elevated gamma globulin levels, possibly increased WBC
Positive evoked potentials
Factors that give a positive prognosis with MS
Female
Younger than 35 at onset
Monoregional
Complete recovery after exacerbation
Factors that give a poor prognosis with MS
Male
Older than 35 at onset
Brainstem s/s such as nystagmus, tremor, ataxia, dysarthria.
Poor recovery following exacerbations
Frequent attacks
African Americans
Categories of MS
Relapsing-remitting
Primary-progressive
Secondary-progressive
Progressive-relapsing
Relapsing-remitting MS
Most common at dx (85%)
Clearly defined disease flare ups with full recovery or minimal residual deficits
Periods between relapses usually disease free
Secondary progressive MS
50% of people with relapsing-remitting develop this within 10 years.
Initial relapse/remit followed by progression with minor remissions with some recovery and plateau
Primary-progressive MS
Rare (10%)
Disease progression from onset
Without plateaus, or with occasional plateau with minor improvements
Steady increase in disability without “attacks”
Progressive-relapsing MS
Rare (5%)
Progressive from onset
Clear acute relapses, with or without recovery
Periods b/w relapses have continuing progression
Categories of treatment for MS
Treatment of acute exacerbations Symptom management Disease modification Rehabilitaiton Psychological support
Factors triggering a relapse
Unpredictable
Infections-vaccines safe
stress
Heat can increase symptoms, but not established triggers
Last trimester of pregnancy offers natural protection against relapse
MS acute rehab management
Natural improvement over 4-12 wks
IV or oral corticosteroids (little evidence that these alter course of disease)
Avonex
For relapsing forms of MS
weekly IM injection
Adverse reactions: flulike symptoms after injection, depression, anemia, elevated liver enzymes, allery, heart problems.
Rebif
For relapsing forms of MS
3x/wk IM injections
Adverse reactions: flulike symptoms, injection site reactions, liver abnormalities, depression, allergies, low RBC/WBC
Betaseron and Extavia
Relapsing forms of MS
Every other day subQ injections
DO NOT GIVE TO DEPRESSED PEOPLE: increases suicide chance.
Adverse reactions: flulike symptoms, injection site reactions, allergy, depression, elevated liver enzymes, low WBC
Copaxone
For relapsing/remitting MS
Daily subQ
Adverse reactions: injection site reactions, vasodilation, chest pain, anxiety, palpitations, SOB, flushing
Novantrone (Serono)
For worsening relapsing/remitting MS and for progressive relapsing or secondary progressive MS
4x/year IV infusion
Tysabri (natalizumab)
For relapsing forms of MS. Generally recommended for individuals with inadequate response to, or unable to tolerate other MS treatment.
Every 4 weeks IV infusion
Increased risk of progressive multifocal leukoencephalopathy (PML), HA, fatigue, jt pain, diarrhea, rash, abdominal discomfort.
