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
  • Multiple Sclerosis, Therapeutics - Dr. M. Fast

    1. 1. Practical management issues in multiple sclerosis: what to do while waiting for the neurologist. Dr. Mal Fast April 6, 2006
    2. 2. Most common problems of MS patients • Bladder dysfunction • Fatigue • Spasticity • Pain • Depression • Sexual dysfunction
    3. 3. MS patients usually under-treated!
    4. 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. 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. 6. Treatment of fatigue • Treat underlying medical conditions • Mild exercise program, yoga • Proper rest • Cool environment (airconditioning) • Immunomodulators • Amantidine, alertec, caffeine
    7. 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. 8. Treatment of spasticity in MS • Passive and active stretching • Exercise program • Reduce pain, treat infections (bladder, skin) • Medications: baclofen, tizanidine, keppra, botox
    9. 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. 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. 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. 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. 13. Treatment of detrusor areflexia • Hytrin 2-10 mg OD • Urecholine 10-50 mg TID to QID (diarrhea, flushing, sweating) • catheterization
    14. 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. 15. Sexual dysfunction in MS patients • Could be emotional, cognitive, or medication side effects • Usually in patients with spinal MS
    16. 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. 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. 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. 19. Depression in MS patients • 26-57% of MS patients (2-10x population) • SSRIs and tricyclics
    20. 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. 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. 22. What should the neurologist do while waiting for the family doctor?

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