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Multiple Sclerosis, Therapeutics - Dr. M. Fast
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Multiple Sclerosis, Therapeutics - Dr. M. Fast


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  • Of these, only spasticity is treated in more than 40%.
  • Fatigue on awakening think depression.
  • Anemia, hypothyroidism, etc.
  • Spasticity ranges from mild impairment of running to a severe increase in adductor tone interfering with GU hygeine
  • Transcript

    • 1. Practical management issues in multiple sclerosis: what to do while waiting for the neurologist. Dr. Mal Fast April 6, 2006
    • 2. Most common problems of MS patients • Bladder dysfunction • Fatigue • Spasticity • Pain • Depression • Sexual dysfunction
    • 3. MS patients usually under-treated!
    • 4. Fatigue • “A subjective lack of physical and/or mental energy that is perceived by the individual or caregiver to interfere with usual and desired activities.” • 75% of MS patients vs 30% of population • Greatest impediment to mobility in 50%
    • 5. Causes of fatigue in MS patients • Deconditioning • Overuse: physical, mental, heat • Sleep disturbances: PLMS, hypersomnia, insomnia, sleep apnea • Medications: antispasticity, anxiolytics, antiepileptics, analgesics, interferons • Depression, anxiety, social isolation, sense of helplessness • Related to MS attack: frontal cortex and BG
    • 6. Treatment of fatigue • Treat underlying medical conditions • Mild exercise program, yoga • Proper rest • Cool environment (airconditioning) • Immunomodulators • Amantidine, alertec, caffeine
    • 7. Spasticity • “Rigidity that increases with speed of movement” • Ranges from mild impairment with running to severe increases in adductor tone interfering with GU hygiene • May be useful, allowing a patient to stand, pivot and transfer
    • 8. Treatment of spasticity in MS • Passive and active stretching • Exercise program • Reduce pain, treat infections (bladder, skin) • Medications: baclofen, tizanidine, keppra, botox
    • 9. Bladder problems in MS patients • Usually bladder problems in MS patients progress from hyper-reflexia of the detrusor muscle, then detrusor sphincter dyssynergia, then detrusor areflexia • 50-80% of MS patients at sometime in the course of the disease • Rule out other causes: blockage (prostatic hypertrophy), infections
    • 10. Have MS patients keep a diary to help diagnose bladder problems • Voiding frequency, nocturia • Urgency, incontinence • Hesitancy, quality of stream • Urinary volume • With only a clinical history 50% of patients are misdiagnosed
    • 11. Treatment of hyper-reflexic bladder • Reduce bladder stimulants: caffeine, acids • Careful attention to fluid intake, eg reduce when going out • Timed voiding – before the urge • Ditropan 2.5-5 mg TID • Probanthine 15 mg TID • Imipramine 50-300 mg OD • Detrol 2 mg BID
    • 12. Treatment of hyper-reflexic bladder with outlet obstruction (dyssynergia) • Anticholinergics as per hyper-reflexic bladders • PLUS Hytrin 2-10 mg OD • Crede’s maneuver
    • 13. Treatment of detrusor areflexia • Hytrin 2-10 mg OD • Urecholine 10-50 mg TID to QID (diarrhea, flushing, sweating) • catheterization
    • 14. When to refer to a urologist • More than three UTI per year • Post void residuals more than 200 ml • When treatments don’t work • *Remember that only 50% of bladder problems in MS patients are properly diagnosed on the basis of history alone.
    • 15. Sexual dysfunction in MS patients • Could be emotional, cognitive, or medication side effects • Usually in patients with spinal MS
    • 16. Erectile dysfunction men with MS • 50-75% of men with MS • Viagra effective in 90% of these men • Intracavernous papervine, vacuum devices, SSRIs
    • 17. Sexual dysfunction in women with MS • 45-74% of women with MS • Not related to duration or severity of disease • Most common complaints are inadequate lubrication and decreased sensation • Treat with vaginal creams and water soluble jellies • Wellbutrin may increase libido • Treat pain, spasticity, bladder problems, etc
    • 18. Pain in MS patients • 55-65% of MS patients • Usually either constant burning or paroxysmal stabs of pain • Treat with anticonvulsants such as carbamazepine, gabapentin, topamax, lamotrigene, phenytoin
    • 19. Depression in MS patients • 26-57% of MS patients (2-10x population) • SSRIs and tricyclics
    • 20. Treatment of acute attacks • IV solumedrol 500-1000 mg OD for 3 to 7 days • Short (1 week) taper of oral prednisone • Treat only functionally disabling attacks • No long term benefit • Repeated doses beware osteoporosis
    • 21. As important as this information is, it is worth little unless a therapeutic alliance is established with the patient. One must take time to listen carefully to patients. Dr. Michael Kaufman, ‘Treatment of Multiple Sclerosis’
    • 22. What should the neurologist do while waiting for the family doctor?