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Flashcards in Multiple sclerosis Deck (23):

What is MS?
-initial presentation?

an inflammatory demyelinating disorder the central nervous system

Plaques disseminated in time and place

Female:Male = 3:1

Initial presentation in 30s & 40s


What is the pathophysiology of MS?

Lymphocytes cross the BBB and get into brain

Attack myelin cells

Inflammation and plaques



What is the aetiology of MS?

-genetic disposition
-environmental factors
-immune mediated


What are the 4 different courses of MS?

Relapsing remitting 90% :
-relapses over weeks and weeks, progressively gets worse then better

Secondary progressive 60%:
-gradually worsens

Relapsing progressive

Primary progressive 10-15%
-older males, never relapse

60% of relapsing remitting patients develop secondary progressive disease after 10 years


Describe the:
features of MS

optic neuritis: common presenting feature
optic atrophy
Uhthoff's phenomenon: worsening of vision following rise in body temperature
internuclear ophthalmoplegia

-Dorsal column loss
-Proprioception & vibration: Rhombergs test positive (proprioception)
-trigeminal neuralgia
-Lhermitte's syndrome: paraesthesiae in limbs on neck flexion

Motor (due to pyramidal dysfunction)
spastic weakness: most commonly seen in the legs
-weak extensors and strong flexors in the upper limbs and opposite in the lower limbs

-ataxia: more often seen during an acute relapse than as a presenting symptom
-Intention Tremor
-Past pointing
-Pendular reflexes – when -patellar tapped the leg swings


urinary incontinence
sexual dysfunction
intellectual deterioration


Describe what optic neuritis is?

painful visual loss

1 to 2 weeks

most improve

RAPD -relative afferent pupilllary defect

common presenting feature

in 1 eye rather than 2

colour vision goes first


What is internuclear ophthalmoplegia?

Caused by Medial longitudinal fasciculus dysfunction

Distortion of binocular vision

Failure of adduction- diplopia

Nystagmus in abducting eye


In MS one eye may quickly look at something and then the other may have nystagmus.

If have problem in LHS, left medial LF problem so when looking right, left eye fails to adduct and right eye has nystagmus.


Describe the lower urinary tract dysfunction seen in MS?

-urge incontinence
(similar to BPH)


What is the diagnosis of MS?

(mcdonald criteria)

At least 2 episodes suggestive of demyelination

Dissemination in time and place


MRI - diagnosis shows plaques

CSF: oligoclonal bands


Blood tests – these should all be negative


What blood tests are carried out in the investigations of MS?

Plasma viscosity, FBC, CRP

Renal liver bone profile

Auto anti body screen

Borellia, HIV, syphilis serology

B12 and folate


What is a clinically isolated syndrome in MS?

-First presentation suggestive of MS
-can't tell until second event whether they definitely have MS


How to treat a:
exacerbration of MS?

Mild-symptomatic treatment:
-Usually will get better

Moderate-Oral steroids:
-Oral methylprednisolone 500mg per day for 5 days and lansoprazole to protect stomach

Severe-Admit / IV steroids
-Come into hospital and IV methylprednisolone 1’000 mg 3 days

But steroids = side effects so ideally only do this once a year, no more than once every 3 months
-only reduces period of exacerbation


How can spasticity be managed?



Oral medication - baclofen,tizanidine(anti-spasmodics): start low go slow

Side effects: tired/drousy/hypotension so sometimes do nothing due to s/e of treatment

I.M. Botulinum toxin – this is uncommonly used in MS as not a long term solution

Nerve blocks – not long term solution

Intrathecal baclofen / phenol - end stage treatment


Spasticity may be helpful for pt e.g. so weak that can’t stand without spasticity so don’t want to take it all away.


How is MS pain treated?

anti convulsant eg. gabapentin

anti depressant eg. amitriptyline

tens machine


Lignocaine infusion


How is lower urinary tract dysfunction treated in MS?

bladder drill (training)

anti cholinergics eg., oxybutynin (if old tolteridine as oxybutynin can cause dementia)


catheter - clean self intermittent or permanent

there are bladder clinics for MS patients, they do a post micturition ultrasound and see if it’s over 100 – if it is and given anticholinergics (oxybutynin) this can give urinary retention.

If someone has retention >100mls – catheter
can do this themselves 2-3 times a day
can put a permanent catheter for end stage management


How can fatigue be managed in MS?

Fatigue management


Modafinil if sleepy

Hyperbaric oxygen

Occupational therapists can help people understand about their fatigue


Describe the 1st, 2nd and 3rd disease modifying therapy for MS?

First line therapy
-Interferon Beta – Avonex, Rebif, Betaseron, Extavia
-Glitiramer Acetate (Copaxone)

Second line therapy

Third line therapy

Second and third line drugs work better but risk death, 1st line aren’t great but are safe


What is the 1st line:
-does this work?

Interferon beta and copaxone: 1st line

This is common, safe and patients can self administer

Injectable agents – sc, im

Decrease relapse rate by 1/3

Decrease severity of relapses by 50%, for mild it’s less effective

Effect on disability

All comparable re efficacy


What is the step up from 1st line for MS disease modifying therapy?

Tecfidera: step up from 1st line

Oral agent

First line indication in RR MS

44% reduction in relapse rate

Long term data unclear

Bad side effects such as stomach upset and flushing

If have attack on the first line drugs can step up to this


What is the role of tysabri and fingolimod?

= Single disease modifying therapies in highly active relapsing remitting multiple sclerosis (RRMS)

-Patients with rapidly evolving severe relapsing remitting multiple sclerosis

-Patients with high disease activity despite treatment with a interferon


What is assoc. with tysabri?

progressive multifocal leukoencephalopathy (PML) associated with tysabri:

JC virus positive

Single Vs dual therapy

Estimated risk 1/385 after 2 years


what is this?

Oral agent

sphingosine 1-phosphate (S1P) modulator

>50% reduction in relapse rate

Significant effect on disease progression

NICE SMC approved as second line


-what is this used for?
-how is this administereD?
-what is this related to?

Relapsing progressive MS

12 infusions over 2 years

Cardiac toxicity dose related