Some drugs are more useful at specific stages. For example, a doctor may prescribe mitoxantrone at a later, more severe stage of MS. A doctor will monitor how well a drug is working, as there may be adverse effects, and the same drugs do not suit everyone. New drug options coming onto the market are proving to be safer and more effective than some existing ones.
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In patients of African or Asian origin, alternative diagnoses should be considered - eg, AIDS , tropical spastic paraplegia or neuromyelitis optica. Electrophysiology: can detect demyelination in apparently unaffected pathways with characteristic delays.
Visual evoked potential studies should be the first choice. Areas of focal demyelination can also be seen as plaques in the optic nerve, brainstem and spinal cord. By using a contrast agent, active inflammatory plaques can be distinguished from inactive ones. The number and size of lesions do not correlate well with disease activity or progress. It also excludes other lesions producing the symptoms. Cerebrospinal fluid: rise in total protein with increase in immunoglobulin concentration with presence of oligoclonal cases.
Management The management of people with MS should include[ 5 ]: Good communication with patients and their carers. Provision of written information regarding the disease, treatments and available help and support. Informing them of their legal obligation to notify the DVLA of their condition. Ensuring all available help and support with rehabilitation, employment and mobility. Support to the family and carers, including respite care. Close co-operation and communication between all health professionals involved in caring for the person including their GP, nurse specialists and specialists.
Pharmacological Relapses Any episode of sudden increase ie over hours in distressing symptoms or an increased limitation on activities should be assessed promptly. Symptoms should be discussed with a clinician with expertise in MS to decide whether oral or intravenous IV methylprednisolone treatment is required[ 5 ]. A urinary tract infection should be excluded as the cause of the exacerbation of symptoms before steroids are considered.
This is given as a day-case treatment but admission may be arranged if required by the patient. IV infusion is given over four hours. Oral medication as 5 x mg tablets is also available. Patients often notice an unpleasant metallic taste with this treatment. It is no longer considered necessary to taper doses down after this course. Gastric protection should be provided by ranitidine mg bd, or omeprazole 20 mg daily. The use of steroids on more than three occasions per year, or for longer than three weeks on any one occasion, should be avoided.
Disease-modifying therapy NB. Any woman receiving disease-modifying therapy eg, interferon must stop treatment for at least 12 months before trying to conceive. Disease-modifying drugs are the recommended treatment for active relapsing-remitting multiple sclerosis. Interferon beta and glatiramer acetate may be preferred because of their established safety profile, and long-term clinical experience associated.
Peginterferon beta-1a requires less frequent administration. Teriflunomide and dimethyl fumarate are also treatment options for patients with active disease. More active disease may be treated with natalizumab or alemtuzumab. In May , the MHRA published restrictions on the use of alemtuzumab due to reports of serious cardiovascular and immune-mediated reactions.
Natalizumab may be preferred due to the complex safety profile associated with alemtuzumab. Natalizumab is only recommended for the treatment of rapidly-evolving severe relaxing-remitting MS. Fingolimod is the recommended treatment for patients with highly active disease[ 7 ]. Interferon beta: This is licensed for use in patients with relacing-remitting MS characterised by at least two attacks of neurological dysfunction over the previous two or three years, followed by complete or incomplete recovery who are able to walk m unaided.
Not all patients respond and a deterioration in the bouts has been observed in some. Interferon beta-1b is also licensed for use in patients with secondary progressive MS. However immunomodulatory strategies used for relaxing-remitting MS, such as beta interferon, have not proven effective when extended into secondary progressive MS[ 5 ]. Glatiramer: This is licensed for reducing the frequency of relapses in ambulatory patients with relapsing-remitting MS who have had at least two clinical relapses in the previous two years.
It is given daily by subcutaneous injection. Injection site reactions are common, as are flu-like symptoms. These decrease over time. Teriflunomide[ 10 ]: Teriflunomide is recommended by NICE as an option for treating adults with active relapsing-remitting MS normally defined as two clinically significant relapses in the previous two years , only if they do not have highly active or rapidly evolving severe relapsing-remitting MS.
Second-line therapies Natalizumab: This is a recombinant humanised monoclonal antibody, produced in murine myeloma cells. NICE approval was granted in August It is given monthly by IV infusion[ 12 ]. Fingolimod: The first oral therapy for MS. Other treatments Cannabinoids: There is a great deal of anecdotal evidence for the therapeutic benefits of cannabis for a variety of MS symptoms, including spasticity, tremor, bladder problems and pain.
General problems Fatigue First consider and treat any underlying causes - eg, depression, disturbed sleep, chronic pain and poor nutrition. Advise fatigue may become worse with heat and stress. Medication should also be reviewed; some medications eg, interferon beta have fatigue as a side-effect. Advise that aerobic exercise or yoga may be beneficial.
Offer amantadine for fatigue but also consider mindfulness-based training or cognitive behavioural therapy CBT [ 5 ]. Pain This may be of neuropathic origin or from musculoskeletal problems, secondary to reduced mobility. It may need suitable analgesia and, if still a problem, transcutaneous electrical nerve stimulation TENS or antidepressant medication.
Cognitive behavioural and imagery treatment methods may also be beneficial. Neuropathic pain should be treated using anticonvulsants such as carbamazepine or gabapentin , or using antidepressants such as amitriptyline. Visual and communication Visual problems Difficulty in reading or seeing television is not uncommon and the usual reason other than the lack of glasses is that the control over eye movement is poor. Actual loss of visual function due to optic neuritis is rare.
Visual disturbance associated with MS requires an ophthalmological opinion. The patient should be assessed for glasses by an optometrist and, if necessary, at a specialist ophthalmology clinic.
If nystagmus is causing reduced visual acuity or other visual symptoms, offer a trial of treatment with oral gabapentin initiated and monitored in a specialist clinic. May need low-vision equipment and adaptive technology and require to be registered as sight impaired. Speech difficulties Dysarthria may cause great difficulty.
This should be assessed and advice given by a specialist speech and language therapist. May need alternative non-verbal means of assisting with or replacing speech.
Motor problems Exercises and techniques to maximise strength and endurance appropriate to their circumstances, including aerobic training. Motor weakness may require equipment - eg, orthoses or specialist supportive equipment for postural difficulties. Spasticity and spasms: Consider and explore possible aggravating factors - eg, pain, infection.
Advice on physical techniques - eg, passive stretching, to reduce spasticity and avoid the development of contractures. Baclofen or gabapentin are the drugs of choice if required. Tizanidine and dantrolene are recommended second-line treatments if treatment with baclofen or gabapentin is unsuccessful or the side-effects are intolerable.
Benzodiazepines may be used as third-line agents. There are only poor-quality data regarding the comparative efficacy and tolerability of anti-spasticity agents and a Cochrane review concluded that no recommendations could be made to guide prescribing[ 15 ]. Troublesome spasticity and spasms should be assessed by a specialist team. Intramuscular botulinum toxin can be considered for relatively localised hypertonia or spasticity that is not responding to other treatments.
Contractures at joints: specific treatments include prolonged stretching - eg, with serial plaster casts. Ataxia and tremor: Should be assessed by a specialist rehabilitation team. If problems remain severe and intractable, the person should also be assessed by a neurosurgical team for suitability for operative intervention.
Pressure ulcers: Many people with MS are at high risk of developing pressure ulcers because of, for example, limited mobility, impairment of sensory functioning and reduced cognitive function. Most pressure ulcers can be avoided. Urological Bladder symptoms: check for underlying urinary tract infection and assess postmicturition residual bladder volume by ultrasound.
Urgency or urge incontinence: Offer convene drain for men or pads for women ; consider toilet arrangements eg, a commode downstairs and intermittent self-catheterisation if there is a high residual volume. Consider anticholinergics eg, oxybutynin, tolterodine. Desmopressin may be used for night problems or to control urinary frequency during the day but should never be used more than once in 24 hours.
Continued incontinence, despite treatment, can be treated by a course of pelvic floor exercises preceded by a course of electrical stimulation of the pelvic floor muscles. Continued bladder symptoms may require intermittent self-catheterisation or longer-term urethral catheterisation. Suprapubic catheterisation is useful if active sexual function is wanted.
Gastroenterological Urgency, pain, constipation or incontinence may occur. Faecal incontinence may be due to constipation with overflow, possibly exacerbated by laxative use.
Constipation may require the routine use of suppositories or enemas. Swallowing difficulties: Dysphagia may lead to choking and aspiration of food or liquid, leading to chest infections. Assessment is advised if there are any symptoms or chest infections. Should be assessed by a specialist speech and language therapist and given advice on specific swallowing techniques and on adapting food consistencies and dietary intake.
May need further assessment eg, by videofluoroscopy , possibly short-term nutritional support via nasogastric tube or percutaneous endoscopic gastrostomy PEG tubes. Higher functions Cognitive losses: About half of all people with MS may have impaired ability to learn and remember, to plan, to concentrate and to handle information quickly. If such problems occur, review medication and assess for depression.
A formal neuropsychological assessment by a specialist clinical psychologist and speech and language therapist if appropriate.
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