MS MG Monday March 16 2015 9 30 PM Multiple Sclerosis 1 2 3 4 5 Objective 1 Evaluate the appropriateness of a therapeutic regimen for acute relapse treatment Objective 2 Compare and contrast disease modifying agents in terms of efficacy safety ease of administration place in therapy and patient specific considerations Objective 3 Develop an evidence based treatment plan for pharmacotherapy based on MS disease course and patient specific factors including dose route and frequency of administration Objective 4 Synthesize pertinent counseling points for a therapeutic regimen containing an ABC R agent Objective 5 Identify therapeutic goals and outcome measures for a patient started on MS therapy Multiple sclerosis is an inflammatory demyelinating disease of the CNS It is an autoimmune disease where the cause is unknown The demyelination of the neurons prevents the neurons from sending signals Those at risk Women White descent Blacks are more at risk of having a progressive form 1st degree relative with MS People living above the 37th parallel before they turned 15 yo If 16 yo moving from south to northern America less at risk If 14 yo moving from south to northern America more at risk Diagnosis peak is around 40 yo Favorable Prognosis Unfavorable Prognosis 40yo female initial sx was optic neuritis low frequency of attack course of disease relapsing remitting 40yo male initial sx of motor or cerebellar sx high frequency of attacks in early disease progressive course of disease Prognosis says life expectancy is only shortened slightly Mortality results usually from secondary complications pulmonary renal Lhermitte s sign feeling that occurs when pt bends neck to look down Visual complaints gait problems speech difficulty ataxia sexual dysfunction Clinical Presentation Primary Secondary Recurrent UTIs Depression Tertiary Disease Courses Relapsing remitting MS Primary progressive MS Secondary progressive MS Progressive relapsing MS Diagnosis Mainly done by process of elimination Physical exam balance coordination Lab testing MRI CSF exam Assessment scales Financial personal social vocational emotional Immune cells cause localized areas of damage creating the sx Progression to secondary progressive MS occurs in 80 of pts Kurtzke Expanded disability status scale EDSS Evaluates neurologic functions Limitations in measuring cognition fatigue and affect Range 0 no disability 5 walking on own 10 death McDonald Criteria Assists with diagnosis Brain MRI cerebrospinal fluid CSF and visual evoked potential VEP Pregnancy and MS Relapse rate usually reduced during 3rd trimester with increase postpartum MS meds Most don t have adequate studies Mitoxantrone Class D Teriflunomide Class X Relapse or Exacerbation or Attack Defined as the development of new or recurring symptoms lasting at least 24 hours and separated from a previous attack by at least one month Treatment Methylprednisolone 500 1000mg IV or PO daily Dose is much higher than usual usual is around 4mg Shortens the duration of the attack Onset 2 3 days faster than the other MS meds Duration of treatment is about 3 10 days May delay repeat attacks for up to 2 years after optic neuritis Adverse effects Sleep disturbance metallic taste increase in blood Glu GI upset Goals of therapy Increase quality of life Decrease relapse rate Reduce inflammation and axonal damage Reduce progression of disability Slow accumulation of lesions of MRI FDA Approved Disease Modifying Agents 1st line treatment ABC R Equally efficacious vs each other Interferon beta 1b Betaseron Extavia Dose 250 mcg 0 25mg SC every other day Starting dose is around 62 5 mcg or 0 0625mg Storage Does NOT require refrigeration Self administered May meet barriers due to inability to manipulate the injections Class warnings Liver dysfunction Severe leukopenia low WBC Thrombocytopenia decrease thrombus formation increase risk of bleeding Pregnany Lactation Test 2 Page 1 Generic Brand Interferon beta 1a Avonex Interferon beta 1a Rebif PEGinterferon beta 1a Plegrity Interferon beta 1b Betaseron Interferon beta 1b Extavia Glatiramer acetate Copaxone Teriflunomide Aubagia Tecfidera Fingolimod Alemtuzumab Natalizumab Mitoxantrone Dimethyl Fumarate Gilenya Lemtrada Tysabri Novantrone Class warnings Liver dysfunction Severe leukopenia low WBC Thrombocytopenia decrease thrombus formation increase risk of bleeding Pregnany Lactation Severe depression Avoid if pt is actively suicidal Class Adverse Effects Injection site reactions and or swelling Counseling pt Rotate injection sites use ice packs before and or after injection to decrease irritation Flu like symptoms May cause nonadherence or discontinue Can take APAP to decrease fever and ibuprofen shorter half life for pain Lasts about 24 hours after each injection usually goes away around 1 3 months after start Taper to full dose over 1 2 months Less common tachycardia depression thyroid dysfunction necrosis rare Class Monitoring Baseline Blood counts Platelets LFTs Monitor at baseline 1month every 3 months for a year and every 6 months thereafter Class Counseling pts Allow med to get to RT before administration Hydrocortisone cream can be used for irritation Interferon beta 1a Avonex Rebif Plegrity Avonex Rebif Plegrity Dosing 30 mcg IM once weekly Storage Refrigerate Stable at RT for 7 days Dosing 22 or 44 mcg SC three times a week Storage Refrigerate Stable at RT for 30 days Dosing 125 mcg SC Q14 days every 2 weeks Storage Refrigerate Stable at RT for 30 days Protect from light Has a longer duration of action Class warnings Liver dysfunction Severe leukopenia low WBC Thrombocytopenia decrease thrombus formation increase risk of bleeding Pregnany Lactation Severe depression Avoid if pt is actively suicidal Class Adverse Effects Injection site reactions and or swelling Counseling pt Rotate injection sites use ice packs before and or after injection to decrease irritation Flu like symptoms May cause nonadherence or discontinue Can take APAP to decrease fever and ibuprofen shorter half life for pain Lasts about 24 hours after each injection usually goes away around 1 3 months after start Taper to full dose over 1 2 months Less common tachycardia depression thyroid dysfunction necrosis rare Baseline Blood counts Platelets LFTs Monitor at baseline 1month every 3 months for a year and every 6 months thereafter Class Monitoring Class Counseling pts Allow med to get to RT before administration Hydrocortisone cream can be used for irritation Interferon